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Fernández S, Grafia I, Peyrony O, Canet E, Vigneron C, Monet C, Issa N, Decavele M, Moreau AS, Lautrette A, Lacave G, Morel G, Cadoz C, Argaud L, Statlender L, Azem K, Quenot JP, Lesieur O, Fernández J, Farrero M, Marcos MÁ, Lemiale V, Castro P, Azoulay É. Clinical characteristics and outcomes of immunocompromised critically ill patients with cytomegalovirus end-organ disease: a multicenter retrospective cohort study. Crit Care 2024; 28:243. [PMID: 39014504 PMCID: PMC11251242 DOI: 10.1186/s13054-024-05029-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 07/08/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection in patients with cellular immune deficiencies is associated with significant morbidity and mortality. However, data on CMV end-organ disease (CMV-EOD) in critically ill, immunocompromised patients are scarce. Our objective here was to describe the clinical characteristics and outcomes of CMV-EOD in this population. METHODS We conducted a multicenter, international, retrospective, observational study in adults who had CMV-EOD and were admitted to any of 18 intensive care units (ICUs) in France, Israel, and Spain in January 2010-December 2021. Patients with AIDS were excluded. We collected the clinical characteristics and outcomes of each patient. Survivors and non-survivors were compared, and multivariate analysis was performed to identify risk factors for hospital mortality. RESULTS We studied 185 patients, including 80 (43.2%) with hematologic malignancies, 55 (29.7%) with solid organ transplantation, 31 (16.8%) on immunosuppressants, 16 (8.6%) with solid malignancies, and 3 (1.6%) with primary immunodeficiencies. The most common CMV-EOD was pneumonia (n = 115, [62.2%] including 55 [47.8%] with a respiratory co-pathogen), followed by CMV gastrointestinal disease (n = 64 [34.6%]). More than one organ was involved in 16 (8.8%) patients. Histopathological evidence was obtained for 10/115 (8.7%) patients with pneumonia and 43/64 (67.2%) with GI disease. Other opportunistic infections were diagnosed in 69 (37.3%) patients. Hospital mortality was 61.4% overall and was significantly higher in the group with hematologic malignancies (75% vs. 51%, P = 0.001). Factors independently associated with higher hospital mortality were hematologic malignancy with active graft-versus-host disease (OR 5.02; 95% CI 1.15-27.30), CMV pneumonia (OR 2.57; 95% CI 1.13-6.03), lymphocytes < 0.30 × 109/L at diagnosis of CMV-EOD (OR 2.40; 95% CI 1.05-5.69), worse SOFA score at ICU admission (OR 1.18; 95% CI 1.04-1.35), and older age (OR 1.04; 95% CI 1.01-1.07). CONCLUSIONS Mortality was high in critically ill, immunocompromised patients with CMV-EOD and varied considerably with the cause of immunodeficiency and organ involved by CMV. Three of the four independent risk factors identified here are also known to be associated with higher mortality in the absence of CMV-EOD. CMV pneumonia was rarely proven by histopathology and was the most severe CMV-EOD.
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Affiliation(s)
- Sara Fernández
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain.
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
| | - Ignacio Grafia
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain
- Department of Medical Oncology, IDIBAPS, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, CHU de Nantes, Université de Nantes, Nantes, France
| | - Clara Vigneron
- Médecine Intensive et Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Clément Monet
- Anesthesia and Critical Care Department, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS, Montpellier, France
| | - Nahéma Issa
- Medical Intensive Care Unit, Hôpital Saint André, CHU Bordeaux, Bordeaux, France
| | - Maxens Decavele
- Medical Intensive Care Unit (Department R3S), Pitié-Salpêtrière University Hospital, Sorbonne University Hospitals, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- INSERM Research Unit UMRS1158, Experimental and Clinical Respiratory Neurophysiology, Sorbonne University, Paris, France
| | | | - Alexandre Lautrette
- Medical Intensive Care Unit, Jean Perrin Oncology Institut and Montpied Teaching Hospital, Clermont-Ferrand, France
| | - Guillaume Lacave
- Medical-Surgical Intensive Care Unit, Versailles Hospital Center, Le Chesnay, France
| | - Guillaume Morel
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | - Cyril Cadoz
- Réanimation Polyvalente, CHR Metz-Thionville Hôpital de Mercy, Metz, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Liran Statlender
- General Intensive Care Unit, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karam Azem
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Anesthesiology Department, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Jean-Pierre Quenot
- Deparment of Intensive Care, Burgundy University Hospital, Dijon, France
| | - Olivier Lesieur
- Intensive Care Unit, La Rochelle General Hospital, La Rochelle, France
| | - Javier Fernández
- Liver Intensive Care Unit, Hospital Clinic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- EF-Clif, Barcelona, Spain
| | - Marta Farrero
- Heart Failure Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Mª Ángeles Marcos
- Microbiology Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Virgine Lemiale
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Élie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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2
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Şener YZ, Gultekin AE, Guler AC, Canpolat U, Alp S. A Challenging Case of Viral Pneumonia in the COVID-19 Pandemic Era. Cureus 2024; 16:e59360. [PMID: 38817494 PMCID: PMC11137628 DOI: 10.7759/cureus.59360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/01/2024] Open
Abstract
Cytomegalovirus (CMV) is a DNA virus that can cause widespread, severe infection in immunocompromised patients. While CMV usually leads to a subclinical infection in immunocompetent individuals, it can rarely cause severe disease in this population. The SARS-CoV-2 virus is an RNA virus and part of the Coronaviridae family. SARS-CoV-2 led to the COVID-19 (coronavirus disease 2019) pandemic. Even though COVID-19 usually presents with signs and symptoms of upper respiratory tract infection in younger adults, viral pneumonia, cytopenia, and neurological symptoms become more apparent with increasing age. Herein, we describe an immunocompetent 73-year-old female patient in whom oxygen demand and pancytopenia developed during hospitalization for post-ablation inguinal access site infection. The thorax CT revealed viral pneumonia, but two subsequent SARS-CoV-2 polymerase chain reaction (PCR) tests and a viral respiratory multiplex PCR panel were negative. The CMV viral load was high in the blood sample, and the patient responded to valganciclovir treatment. Although SARS-CoV-2 should be evaluated in patients with viral pneumonia and cytopenia, other viral etiologies mimicking SARS-CoV-2 infection, such as CMV, should not be overlooked in the era of the COVID-19 pandemic.
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Affiliation(s)
- Yusuf Ziya Şener
- Cardiology Department, Hacettepe University Faculty of Medicine, Ankara, TUR
| | - Ahmet Emre Gultekin
- Cardiology Department, Hacettepe University Faculty of Medicine, Ankara, TUR
| | - Akif Can Guler
- Internal Medicine Department, Hacettepe University Faculty of Medicine, Ankara, TUR
| | - Ugur Canpolat
- Cardiology Department, Hacettepe University Faculty of Medicine, Ankara, TUR
| | - Sehnaz Alp
- Infectious Diseases Department, Hacettepe University Faculty of Medicine, Ankara, TUR
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3
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Bhide M, Singh O, Nasa P, Juneja D. Cytomegalovirus infection in non-immunocompromised critically ill patients: A management perspective. World J Virol 2024; 13:89135. [PMID: 38616856 PMCID: PMC11008403 DOI: 10.5501/wjv.v13.i1.89135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 03/11/2024] Open
Abstract
Critically ill patients are a vulnerable group at high risk of developing secondary infections. High disease severity, prolonged intensive care unit (ICU) stay, sepsis, and multiple drugs with immunosuppressive activity make these patients prone to immuneparesis and increase the risk of various opportunistic infections, including cytomegalovirus (CMV). CMV seroconversion has been reported in up to 33% of ICU patients, but its impact on patient outcomes remains a matter of debate. Even though there are guidelines regarding the management of CMV infection in immunosuppressive patients with human immunodeficiency virus/ acquired immuno deficiency syndrome, the need for treatment and therapeutic approaches in immunocompetent critically ill patients is still ambiguous. Even the diagnosis of CMV infection may be challenging in such patients due to non-specific symptoms and multiorgan involvement. Hence, a better understanding of the symptomatology, diagnostics, and treatment options may aid intensive care physicians in ensuring accurate diagnoses and instituting therapeutic interventions.
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Affiliation(s)
- Madhura Bhide
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
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4
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Schwab SC, Yamamoto AY, Aragon DC, Carlotti APDCP. Cytomegalovirus Active Infection in Critically Ill Children. Pediatr Infect Dis J 2023; 42:875-882. [PMID: 37523581 DOI: 10.1097/inf.0000000000004027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
OBJECTIVE To describe the epidemiology, clinical characteristics and outcomes of children with cytomegalovirus (CMV) active infection in the pediatric intensive care unit (PICU) and to investigate risk factors for mortality. METHODS This was a retrospective cohort study of patients who had CMV DNA detected in blood samples and/or tracheal aspirates by polymerase chain reaction (PCR) during stay at 2 PICUs of a university hospital. Suspected cases without etiological confirmation and patients with laboratory-confirmed CMV infection before PICU admission were excluded. RESULTS Demographic, clinical and outcome data were collected from medical records. From January 1, 2012, to December 31, 2019, 4748 children were admitted to the PICUs. Thirty-five (0.74%; 95% CI 0.51%-1.02%) had laboratory-confirmed CMV active infection; 71.4% were immunocompromised and 11 (31.4%) died. Patients who died were older than those who survived (median age 65 vs. 5.5 months, respectively; P = 0.048), and they received antiviral therapy for a shorter time (median 12 vs. 23 days, respectively; P = 0.001). The main causa mortis was septic shock (82%) and in most deceased patients (73%) the last CMV PCR before death was positive. PELOD score >6 was a risk factor for death (RR 2.96; 95% CI 1.07-8.21). Viral load in blood had a poor ability for the prediction of death (area under the receiver operating characteristic curve 0.62; 95% CI 0.37-0.84). CONCLUSIONS The incidence of CMV active infection during PICU stay was 0.74% in an upper-middle income country with a high CMV seroprevalence. PELOD score higher than 6 was a risk factor for death. No association was observed between CMV viral load and mortality.
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Affiliation(s)
| | - Aparecida Yulie Yamamoto
- Laboratory of Virology, Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Davi Casale Aragon
- From the Department of Pediatrics, Division of Pediatric Critical Care Medicine
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5
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Diaz-Decaro J, Myers E, Mucha J, Neumann M, Lewandowski W, Kaczanowska M, Schmidt E, Natenshon A, Talarico C, Buck PO. A systematic literature review of the economic and healthcare resource burden of cytomegalovirus. Curr Med Res Opin 2023; 39:973-986. [PMID: 37395088 DOI: 10.1080/03007995.2023.2222583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 05/22/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE Cytomegalovirus (CMV) can infect individuals at any age, including infants, who may contract it from infected mothers (congenital CMV [cCMV]). Whereas CMV infection is typically asymptomatic or causes mild illness in healthy individuals, infection can result in severe outcomes in immunocompromised individuals and in infants with cCMV. This systematic review aims to characterize the economic impact of CMV and cCMV infections. METHODS Medline, Embase, and LILACS databases were searched for publications reporting the economic impact of cCMV and CMV infections across all age groups. Manuscripts published between 2010 and 2020 from Australia, Latin America, Canada, Europe, Israel, Japan, the United States, and global (international, worldwide) studies were included; congress materials were excluded. Outcomes of interest included cCMV- and CMV-attributable direct costs/charges, resource utilization, and indirect/societal costs. RESULTS Of 751 records identified, 518 were excluded based on duplication, population, outcome, study design, or country. Overall, 55 articles were eligible for full-text review; 25 were further excluded due to population, outcome, study design, or congress abstract. Two publications were additionally identified, resulting in economic impact data compiled from 32 publications. Of these, 24 publications reported cost studies of cCMV or CMV, including evaluation of direct costs/charges, healthcare resource utilization, and indirect/societal costs, and 7 publications reported economic evaluations of interventions. The populations, methods and outcomes used across these studies varied widely. CONCLUSIONS CMV and cCMV infections impose a considerable economic impact on different countries, populations, and outcomes. There are substantial evidence gaps where further research is warranted.
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Affiliation(s)
| | - Evan Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
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Schinas G, Moustaka V, Polyzou E, Almyroudi MP, Dimopoulos G, Akinosoglou K. Targeting CMV Reactivation to Optimize Care for Critically Ill COVID-19 Patients: A Review on the Therapeutic Potential of Antiviral Treatment. Viruses 2023; 15:v15051165. [PMID: 37243251 DOI: 10.3390/v15051165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Cytomegalovirus (CMV) reactivation has been linked to adverse clinical outcomes in critically ill patients, with emerging evidence suggesting a potential connection with severe COVID-19. Mechanisms driving this association may include primary lung injury, amplification of systemic inflammation, and secondary immunosuppression. Diagnostic challenges in detecting and assessing CMV reactivation necessitate a comprehensive approach to improve accuracy and inform treatment decisions. Currently, there is limited evidence on the efficacy and safety of CMV pharmacotherapy in critically ill COVID-19 patients. Although insights from non-COVID-19 critical illness studies suggest a potential role for antiviral treatment or prophylaxis, the risks and benefits must be carefully balanced in this vulnerable patient population. Understanding the pathophysiological role of CMV in the context of COVID-19 and exploring the advantages of antiviral treatment are crucial for optimizing care in critically ill patients. This review provides a comprehensive synthesis of available evidence, emphasizing the need for additional investigation to establish the role of CMV treatment or prophylaxis in the management of severe COVID-19 and to develop a framework for future research on this topic.
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Affiliation(s)
| | - Vasiliki Moustaka
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Eleni Polyzou
- Medical School, University of Patras, 26504 Patras, Greece
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
| | - Maria Panagiota Almyroudi
- Department of Emergency Medicine, University Hospital ATTIKON, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - George Dimopoulos
- 3rd Department of Critical Care, EVGENIDIO Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Karolina Akinosoglou
- Medical School, University of Patras, 26504 Patras, Greece
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
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7
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Conway Morris A, Smielewska A. Viral infections in critical care: a narrative review. Anaesthesia 2023; 78:626-635. [PMID: 36633460 PMCID: PMC10952373 DOI: 10.1111/anae.15946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/13/2023]
Abstract
Viral infections form a substantial part of the intensive care workload, even before the recent and ongoing COVID-19 pandemic. The growing availability of molecular diagnostics for viral infections has led to increased recognition of these pathogens. This additional information, however, provides new challenges for interpretation and management. As the SARS-CoV-2 pandemic has amply demonstrated, the emergence and global spread of novel viruses are likely to provide continued challenges for critical care physicians into the future. This article will provide an overview of viral infections relevant to the critical care physician, discussing the diagnosis and management of respiratory viral infections, blood borne and enteric viruses. We will also discuss herpesviridae complications, commonly seen due to reactivation of latent infections. Further, we explore some rarer and emerging viruses, including recognition of viral haemorrhagic fevers, and briefly discuss post-viral syndromes which may present to the intensive care unit. Finally, we will discuss infection control and its importance in preventing nosocomial viral transmission.
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Affiliation(s)
- A. Conway Morris
- Division of Anaesthesia, Department of MedicineUniversity of CambridgeUK
- John V Farman Intensive Care UnitAddenbrooke's HospitalCambridgeUK
| | - A. Smielewska
- Department of Clinical Virology, LCL, CSSBLiverpool University Hospitals NHS Foundation TrustLiverpoolUK
- School of Clinical MedicineUniversity of LiverpoolUK
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Chevalier K, Schmidt J, Coppo P, Galicier L, Noël N, Lambotte O. Hemophagocytic Lymphohistiocytosis Associated With Cytomegalovirus Infection: 5 Cases and a Systematic Review of the Literature. Clin Infect Dis 2023; 76:351-358. [PMID: 35974465 DOI: 10.1093/cid/ciac649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/30/2022] [Accepted: 08/09/2022] [Indexed: 01/18/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder characterized by an uncontrolled, persistent, hyperimmune response. It can be triggered by an infectious, neoplastic, or autoimmune event. The involvement of cytomegalovirus (CMV) in the onset of HLH is subject to debate, and the epidemiology of CMV-associated HLH (HLH-CMV) remains poorly characterized. We identified 5 cases of HLH-CMV in our hospital, systematically searched the PubMed database for publications on HLH-CMV, and reviewed 57 publications with a total of 67 cases of HLH-CMV. Only 48 patients (71.6%) were immunodeficient, suggesting that HLH-CMV can occur in immunocompetent patients. The major cause of underlying immunodepression (51%) was inflammatory bowel disease (mainly treated with azathioprine). CMV infection was nearly always symptomatic, and lung involvement was frequent (31 cases). Fifty-five patients recovered. Nineteen patients were treated for CMV infection only and had a good outcome, suggesting that antiviral drugs might be the cornerstone of HLH-CMV treatment.
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Affiliation(s)
- Kevin Chevalier
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Julien Schmidt
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Paul Coppo
- Sorbonne Université, AP-HP, Hôpital St. Antoine, service d'hématologie clinique et thérapie cellulaire, Paris, France
| | - Lionel Galicier
- Université Paris Cité, AP-HP, Hôpital Saint-Louis, service d'immunologie clinique, Paris, France
| | - Nicolas Noël
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
| | - Olivier Lambotte
- Université Paris-Saclay, AP-HP, Hôpital Bicêtre, service de Médecine Interne Immunologie Clinique, Centre de recherche en Immunologie des infections virales et des maladies auto-immunes ImVA, UMR1184, INSERM, CEA, Le Kremlin Bicêtre, France
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9
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Shen HC, Feng JY, Sun CY, Huang JR, Chen YM, Chen WC, Yang KY. Analysis of the effect of cytomegalovirus infection in clinical outcomes and prolonged duration of SARS-CoV-2 shedding in intensive care unit patients with COVID-19 pneumonia. Ther Adv Respir Dis 2023; 17:17534666231209150. [PMID: 37949827 PMCID: PMC10640799 DOI: 10.1177/17534666231209150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is a global outbreak disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Cytomegalovirus (CMV) infection can occur in critical COVID-19 patients and is associated with adverse clinical outcomes. OBJECTIVE The aim of this study was to explore the clinical characteristics and outcome of CMV infection in critical COVID-19 patients. DESIGN This was a retrospective cohort study. METHODS From May to September 2021, SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR)-confirmed COVID-19 patients with intensive care unit (ICU) admission were enrolled. CMV infection was confirmed by PCR. Baseline characteristics, critical illness data and clinical outcomes were recorded and analyzed. RESULTS Seventy-two RT-PCR-confirmed COVID-19 patients with ICU admission were included during the study period and 48 (66.7%) patients required mechanical ventilation (MV). Overall, in-hospital mortality was 19.4%. Twenty-one (29.2%) patients developed CMV infection. Patients with CMV infection had a higher likelihood of diabetes, higher lactate dehydrogenase and lactate levels, and higher proportions of MV, anticoagulant, and steroid use. Patients with CMV infection were associated with longer duration of SARS-CoV-2 shedding, longer ICU and hospital stay, and fewer ventilator-free days. The independent risk factor for development of CMV infection was a higher accumulative steroid dose. CONCLUSION CMV infection adversely impacted the outcomes of critical COVID-19 patients, resulting in longer ICU stays, longer mechanical ventilation uses and prolonged shedding of SARS-CoV-2.
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Affiliation(s)
- Hsiao-Chin Shen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- Department of Medical Education, Taipei Veterans General Hospital, Taipei
| | - Jia-Yih Feng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chuan-Yen Sun
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
| | - Jhong-Ru Huang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
| | - Yuh-Min Chen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wei-Chih Chen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei
- Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, Institute of Emergency and Critical Care Medicine and School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Cancer Progression Research Center, National Yang Ming Chiao Tung University, Taipei, #201, Sec. Shih-Pai Road, Taipei 11217
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10
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A high CMV-specific T cell response associates with SARS-CoV-2-specific IL-17 T cell production. Med Microbiol Immunol 2023; 212:75-91. [PMID: 36512097 PMCID: PMC9745694 DOI: 10.1007/s00430-022-00758-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
Human cytomegalovirus (CMV) is a widespread persistent herpes virus requiring lifelong immune surveillance to maintain latency. Such long-term interactions with the immune system may be associated with deleterious effects including immune exhaustion and senescence. Regarding the COVID-19 pandemic, we asked whether CMV-specific cellular and humoral activity could influence immune responses toward SARS-CoV-2 and/or disease severity. All adults with mild (n = 15) and severe (n = 14) COVID-19 were seropositive for anti-CMV IgG, but negative for IgM antibodies. Antibody titers did not correlate with COVID-19 severity. Six patients presented elevated frequencies of CMV-specific CD4 + and CD8 + T cells producing IFNγ, IL-17, and TNFα, designated as CMV high responders (hiT CMV). In comparison to low CMV responders, hiT CMV individuals exhibited higher frequencies of SARS-CoV-2-specific CD4 + IL-17 + and CD8 + IFNγ + , IL-17 + or TNFα + T cells. These results indicate that high frequencies of CMV-specific T cells may be associated with a SARS-CoV-2-reactive profile skewed toward Th17-dominated immunity.
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Saura O, Chommeloux J, Levy D, Assouline B, Lefevre L, Luyt CE. Updates in the management of respiratory virus infections in ICU patients: revisiting the non-SARS-CoV-2 pathogens. Expert Rev Anti Infect Ther 2022; 20:1537-1550. [PMID: 36220790 DOI: 10.1080/14787210.2022.2134116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although viruses are an underestimated cause of community-acquired pneumonias (CAP) and hospital-acquired pneumonias (HAP)/ventilator-associated pneumonias (VAP) in intensive care unit (ICU) patients, they have an impact on morbidity and mortality. AREAS COVERED In this perspective article, we discuss the available data regarding the management of severe influenza CAP and herpesviridae HAP/VAP. We review diagnostic and therapeutic strategies in order to give clear messages and address unsolved questions. EXPERT OPINION Influenza CAP affects yearly thousands of people; however, robust data regarding antiviral treatment in the most critical forms are scarce. While efficacy of oseltamivir has been investigated in randomized controlled trials (RCT) in uncomplicated influenza, only observational data are available in ICU patients. Herpesviridae are an underestimated cause of HAP/VAP in ICU patients. Whilst incidence of herpesviridae identification in samples from lower respiratory tract of ICU patients is relatively high (from 20% to 50%), efforts should be made to differentiate local reactivation from true lung infection. Only few randomized controlled trials evaluated the efficacy of antiviral treatment in herpesviridae reactivation/infection in ICU patients and all were exploratory or negative. Further studies are needed to evaluate the impact of such treatment in specific populations.
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Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Juliette Chommeloux
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David Levy
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lucie Lefevre
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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12
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Takagi I, Akiyama H, Matsuba H, Rikitake J, Kozuki Y, Miyata Y, Nakanishi M, Inaba M, Iwata N, Kakiuchi S. Cytomegalovirus Oophoritis Mimicking Burkitt's Lymphoma Recurrence: A Case Report and Literature Review. Intern Med 2022. [PMID: 36261376 DOI: 10.2169/internalmedicine.0517-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cytomegalovirus (CMV) oophoritis is an extremely rare and fatal condition. We encountered a 63-year-old woman with CMV oophoritis who had been treated for Burkitt's lymphoma. Positron emission tomography/computed tomography performed after chemotherapy showed a high 18F-fluoro-2deoxy-D-glucose uptake in both ovaries, which required distinguishing relapse. CMV oophoritis was diagnosed on histology following bilateral salpingo-oophorectomy. Although the patient later developed recurrent episodes of CMV antigenemia, after which complications of CMV retinitis appeared, and she ultimately died of CMV meningitis, surgical resection with antiviral medication resolved her abdominal symptoms and cleared CMV antigenemia for several weeks. It is therefore worth considering surgical resection in combination with antiviral drugs as a treatment option.
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Affiliation(s)
- Ikumi Takagi
- Department of Hematology, Yodogawa Christian Hospital, Japan
| | - Hiroaki Akiyama
- Department of Hematology, Yodogawa Christian Hospital, Japan
| | | | - Junpei Rikitake
- Department of Hematology, Yodogawa Christian Hospital, Japan
| | - Yoko Kozuki
- Department of Hematology, Yodogawa Christian Hospital, Japan
| | - Yoshiharu Miyata
- Division of Bioresource Research and Development, Department of Social/Community Medicine and Health, Kobe University Graduate School of Medicine, Japan
| | - Mai Nakanishi
- Department of Pathology, Yodogawa Christian Hospital, Japan
| | - Mayumi Inaba
- Department of Pathology, Yodogawa Christian Hospital, Japan
| | - Nobuko Iwata
- Department of Hematology, Yodogawa Christian Hospital, Japan
| | - Seiji Kakiuchi
- Department of Hematology, Yodogawa Christian Hospital, Japan
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13
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Zhang Z, Li R, Chen Y, Zhang J, Zheng Y, Xu M, Liang J, Li J, Huang Y, Xu Y, He W, Liu X, Li Y. Association between active cytomegalovirus infection and lung fibroproliferation in adult patients with acute respiratory distress syndrome: a retrospective study. BMC Infect Dis 2022; 22:788. [PMID: 36241980 PMCID: PMC9562065 DOI: 10.1186/s12879-022-07747-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 09/20/2022] [Indexed: 12/05/2022] Open
Abstract
Background Cytomegalovirus (CMV) has high seroprevalence, and its active infection is associated with several adverse prognoses in adult patients with acute respiratory distress syndrome (ARDS). However, the role of active CMV infection in ARDS-associated fibroproliferation is unknown. This study aimed at determining the association between active CMV infection and lung fibroproliferation in adult patients with ARDS. Methods We retrospectively reviewed the medical records of all adult patients with ARDS who were admitted to the intensive care unit (ICU) from January 2018 to December 2020 at a national university-affiliated hospital in China. Study subjects were divided into active and non-active CMV infection groups based on CMV DNAemia within a 28-day ICU hospitalization. Lung fibroproliferation was measured using chest high-resolution computed tomography (HRCT) and N-terminal peptide of serum procollagen III (NT-PCP-III) within the first 28 days of ICU admission. Pulmonary fibrosis, clinical features, laboratory findings, treatment measures, and clinical outcomes were compared between the two groups. Results Among the 87 ARDS patients included in this study, the incidence of active CMV infection was 16.1% within the 28-day ICU admission period. In logistic regression analyze, active CMV infection was found to be associated with higher pulmonary fibrogenesis, pulmonary fibrosis score, and NT-PCP-III level (P < 0.05). The duration of ICU stay in ARDS patients with active CMV infection was significantly higher than in those without active CMV infection (P < 0.05). Conclusions Among adult patients with ARDS, active CMV infection was related to poor clinical outcomes. Active CMV infection was associated with ARDS-associated fibroproliferation. Prophylactic and preemptive use of anti-CMV agents on pulmonary fibrosis should be assessed to determine a consensus therapeutic strategy. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07747-y.
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Affiliation(s)
- Zhihui Zhang
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Rujian Li
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Yubiao Chen
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Jierong Zhang
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Yongxin Zheng
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Minmin Xu
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Jiaqi Liang
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Jiahui Li
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Yongbo Huang
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Yonghao Xu
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Weiqun He
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Xiaoqing Liu
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.
| | - Yimin Li
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.
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14
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Severe, Progressive Meningoencephalitis in a Patient with Coexisting SARS-CoV-2 and Cytomegalovirus Infection: A Case Report. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2022. [DOI: 10.5812/archcid-126363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
: SARS-CoV-2, the pathogen responsible for COVID-19, has infected hundreds of millions since its emergence in late December 2019. Recently, concern has been raised due to the increased prevalence of co-infections with opportunistic pathogens among these patients. Though not common, co-infections may be associated with adverse outcomes and increased risk of morbidity and mortality among patients suffering from COVID-19. Cytomegalovirus (CMV) infection is a serious problem among immunocompromised and critically ill patients. So far, few cases of co-infection with COVID-19 and CMV have been reported. Here, we report the co-infection with COVID-19 and CMV in a young woman presenting with sudden, progressive fever, delusion, agitation, bizarre behavior, seizure, and loss of consciousness leading to death despite receiving appropriate anti-viral treatment. To the best of our knowledge, this is the first case of coexisting SARS-CoV-2 and CMV infection presenting with severe, progressive meningoencephalitis in the era of COVID-19.
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15
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Luyt CE, Burrel S, Mokrani D, Pineton de Chambrun M, Luyt D, Chommeloux J, Guiraud V, Bréchot N, Schmidt M, Hekimian G, Combes A, Boutolleau D. Herpesviridae lung reactivation and infection in patients with severe COVID-19 or influenza virus pneumonia: a comparative study. Ann Intensive Care 2022; 12:87. [PMID: 36153427 PMCID: PMC9509504 DOI: 10.1186/s13613-022-01062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/12/2022] [Indexed: 11/12/2022] Open
Abstract
Background Lung reactivations of Herpesviridae, herpes simplex virus (HSV) and cytomegalovirus (CMV) have been reported in COVID-19 patients. Whether or not those viral reactivations are more frequent than in other patients is not known. Methods Retrospective monocentric cohort study of 145 patients with severe COVID-19 pneumonia requiring invasive mechanical ventilation and who were tested for HSV and CMV in bronchoalveolar lavage performed during fiberoptic bronchoscopy for ventilator-associated pneumonia suspicion. Rates of HSV and CMV lung reactivations, and HSV bronchopneumonitis were assessed and compared with an historical cohort of 89 patients with severe influenza pneumonia requiring invasive mechanical ventilation. Results Among the 145 COVID-19 patients included, 50% and 42% had HSV and CMV lung reactivations, respectively, whereas among the 89 influenza patients, 63% and 28% had HSV and CMV lung reactivations, respectively. Cumulative incidence of HSV lung reactivation (taking into account extubation and death as competing events) was higher in influenza than in COVID-19 patients (p = 0.03), whereas the rate of HSV bronchopneumonitis was similar in both groups (31% and 25%, respectively). Cumulative incidence of CMV lung reactivation (taking into account extubation and death as competing events) was similar in COVID-19 and influenza patients (p = 0.07). Outcomes of patients with HSV or CMV lung reactivations were similar to that of patients without, whatever the underlying conditions, i.e., in COVID-19 patients, in influenza patients, or when all patients were grouped. Conclusions HSV and CMV lung reactivations are frequent in COVID-19 patients, but not more frequent than in patients with influenza-associated severe pneumonia, despite a higher severity of illness at intensive care unit admission of the latter and a longer duration of mechanical ventilation of the former. Although no impact on outcome of HSV and CMV lung reactivations was detected, the effect of antiviral treatment against these Herpesviridae remains to be determined in these patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01062-0.
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16
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Luyt CE. Monocyte: A New Player in the Pathophysiology of Herpes Simplex Virus Reactivation in ICU Patients? Am J Respir Crit Care Med 2022; 206:239-240. [PMID: 35579661 PMCID: PMC9890260 DOI: 10.1164/rccm.202204-0665ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Charles-Edouard Luyt
- Service de Médecine Intensive RéanimationHôpitaux Universitaires Pitié Salpêtrière-Charles FoixParis, France,INSERMUMRS_1166-iCAN Institute of Cardiometabolism and NutritionParis, France
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17
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Shah D, Gupta E, Baweja S, Pasupuleti SSR, Maiwall R, Ramalingam A, Mitra LG, Sarin SK. CYTOMEGALOVIRUS REACTIVATION IN SEROPOSITIVE CRITICALLY ILL PATIENTS WITH LIVER CIRRHOSIS: A HOSPITAL-BASED LONGITUDINAL STUDY. JOURNAL OF CLINICAL VIROLOGY PLUS 2022. [DOI: 10.1016/j.jcvp.2022.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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18
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Blot S, Ruppé E, Harbarth S, Asehnoune K, Poulakou G, Luyt CE, Rello J, Klompas M, Depuydt P, Eckmann C, Martin-Loeches I, Povoa P, Bouadma L, Timsit JF, Zahar JR. Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies. Intensive Crit Care Nurs 2022; 70:103227. [PMID: 35249794 PMCID: PMC8892223 DOI: 10.1016/j.iccn.2022.103227] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients in intensive care units (ICUs) are at high risk for healthcare-acquired infections (HAI) due to the high prevalence of invasive procedures and devices, induced immunosuppression, comorbidity, frailty and increased age. Over the past decade we have seen a successful reduction in the incidence of HAI related to invasive procedures and devices. However, the rate of ICU-acquired infections remains high. Within this context, the ongoing emergence of new pathogens, further complicates treatment and threatens patient outcomes. Additionally, the SARS-CoV-2 (COVID-19) pandemic highlighted the challenge that an emerging pathogen provides in adapting prevention measures regarding both the risk of exposure to caregivers and the need to maintain quality of care. ICU nurses hold a special place in the prevention and management of HAI as they are involved in basic hygienic care, steering and implementing quality improvement initiatives, correct microbiological sampling, and aspects antibiotic stewardship. The emergence of more sensitive microbiological techniques and our increased knowledge about interactions between critically ill patients and their microbiota are leading us to rethink how we define HAIs and best strategies to diagnose, treat and prevent these infections in the ICU. This multidisciplinary expert review, focused on the ICU setting, will summarise the recent epidemiology of ICU-HAI, discuss the place of modern microbiological techniques in their diagnosis, review operational and epidemiological definitions and redefine the place of several controversial preventive measures including antimicrobial-impregnated medical devices, chlorhexidine-impregnated washcloths, catheter dressings and chlorhexidine-based mouthwashes. Finally, general guidance is suggested that may reduce HAI incidence and especially outbreaks in ICUs.
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Affiliation(s)
- Stijn Blot
- Dept. of Internal Medicine & Pediatrics, Ghent University, Ghent, Belgium.
| | - Etienne Ruppé
- INSERM, IAME UMR 1137, University of Paris, France; Department of Bacteriology, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Stephan Harbarth
- Infection Control Program, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Karim Asehnoune
- Department of Anesthesiology and Surgical Intensive Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France
| | - Garyphalia Poulakou
- 3(rd) Department of Medicine, National and Kapodistrian University of Athens, Medical School, Sotiria General Hospital of Athens, Greece
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Jordi Rello
- Vall d'Hebron Institut of Research (VHIR) and Centro de Investigacion Biomedica en Red de Enferemedades Respiratorias (CIBERES), Instituto Salud Carlos III, Barcelona, Spain
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, United States; Department of Medicine, Brigham and Women's Hospital, Boston, United States
| | - Pieter Depuydt
- Intensive Care Department, Ghent University Hospital, Gent, Belgium
| | - Christian Eckmann
- Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Medical University Hannover, Germany
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland; Hospital Clinic, Universidad de Barcelona, CIBERes, Barcelona, Spain
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, CHLO, Lisbon, Portugal; NOVA Medical School, Comprehensive Health Research Center, CHRC, New University of Lisbon, Lisbon Portugal; Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Lila Bouadma
- INSERM, IAME UMR 1137, University of Paris, France; Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jean-Francois Timsit
- INSERM, IAME UMR 1137, University of Paris, France; Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jean-Ralph Zahar
- INSERM, IAME UMR 1137, University of Paris, France; Microbiology, Infection Control Unit, GH Paris Seine Saint-Denis, APHP, Bobigny, France
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19
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Taherifard E, Movahed H, Kiani Salmi S, Taherifard A, Abdollahifard S, Taherifard E. Cytomegalovirus coinfection in patients with severe acute respiratory syndrome coronavirus 2 infection: a systematic review of reported cases. Infect Dis (Lond) 2022; 54:543-557. [PMID: 35522073 DOI: 10.1080/23744235.2022.2070273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Dysfunction of both the innate and the adaptive immune systems is observed in severe coronavirus disease 2019 which, together with administration of immunosuppressive drugs, could lead to cytomegalovirus coinfection or reactivation associated with a poorer outcome. The current study aimed to systematically review the pattern, presentations, clinical course and outcome of patients with severe acute respiratory syndrome coronavirus 2 and cytomegalovirus coinfection. METHODS Three online databases, PubMed, Scopus and Web of Science, were searched, and after excluding duplicates and irrelevant reports, eligible articles were identified. Information about patients' age and gender, comorbidities, presentations of coronavirus disease 2019 and cytomegalovirus, treatment courses and outcomes were extracted. RESULTS A total of 34 reports with 59 patients with coinfection were considered to be eligible for data extraction. A majority of patients were middle-aged or elderly (84.5%). More than three-fourths (79.2%) had at least one comorbidity. Cytomegalovirus viremia was documented in 43 patients. The most common end organ involved was the gastrointestinal tract in 13 patients (48.1% of 27 patients with end organ involvement), mostly as cytomegalovirus colitis, followed by the respiratory tract in 12 patients. There was a significant association between intubation and fatal outcome (p = .011). CONCLUSION We comprehensively reviewed published cases with coronavirus disease 2019 and cytomegalovirus reactivation. The findings may assist in appraising signs and symptoms for early suspicion, detection and treatment in patients with unusual clinical courses or with severe, prolonged or unexplained deterioration of end organ function.
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Affiliation(s)
| | - Hamed Movahed
- Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Sima Kiani Salmi
- Radiology Department, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Ali Taherifard
- Radiology Department, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Saeed Abdollahifard
- Research Center for Neuromodulation and Pain, Shiraz, Fars, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
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20
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Yasuoka K, Fujikawa H, Shibazaki S. Cytomegalovirus enteritis: a surprising cause of severe diarrhoea and protein-losing gastroenteropathy in an intensive care patient. BMJ Case Rep 2022; 15:e249258. [PMID: 35459653 PMCID: PMC9036168 DOI: 10.1136/bcr-2022-249258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
- Kenta Yasuoka
- Department of Emergency and General Internal Medicine, Hitachinaka General Hospital, Hitachinaka, Ibaraki, Japan
| | - Hirohisa Fujikawa
- Department of Emergency and General Internal Medicine, Hitachinaka General Hospital, Hitachinaka, Ibaraki, Japan
- Department of Medical Education Studies, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Shunichi Shibazaki
- Department of Emergency and General Internal Medicine, Hitachinaka General Hospital, Hitachinaka, Ibaraki, Japan
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21
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Seroprevalence of Cytomegalovirus antibodies and primary infection among hemodialysis patients: A systematic and meta-analysis review. Transpl Immunol 2022; 72:101587. [PMID: 35339658 DOI: 10.1016/j.trim.2022.101587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/15/2022] [Accepted: 03/19/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with end-stage renal failure (ESRD) require hemodialysis. According to this point that CMV infection is related to mortality in immunocompromised, and damages in hemodialysis, this study is designed to survey the seroprevalence of CMV and primary infection in hemodialysis (HD) patients. MATERIAL AND METHODS Current cross-sectional studies were found by online reviewing the national and international databases (Web of Science, Pubmed, Scopus, Science Direct, Google scholar), and suitable studies were selected. NOS checklist were used for evaluation of the qualities of all papers. Assessment of heterogeneity among the studies of primary studies was performed using Chi-squared test (Cochran's Q) and I2 index (significance level of 50%). The statistical analysis were performed using Comprehensive Meta-Analysis (CMA) V.2. For assessing publication bias, the Egger test was used by subjective judgment in each study. Also the effect of potential factor on heterogeneity of studies was performed by Meta-regression test and the impact of each study on the overall estimate was assessed by sensitivity analysis. RESULTS This meta- analysis included 23 primary studies investigating seroprevalence of Cytomegalovirus antibodies and primary infection among hemodialysis patients. Finding showed that seroprevalence of CMV IgG and IgM antibodies in hemodialysis patients at 95% confidence interval using random effect model was 88.7% (81.7-93.2%) and 10.9% (5.9-19.2%) respectively. Also the frequency of CMV infection among these studies were reported 41% (18.8-67.6%). CONCLUSION We found that frequency of CMV IgG was higher and it was detected in HD patients. The result of our study showed that most patients were exposure to CMV during dialysis may reactivate by various stimulation, including immunosuppression and inflammation, so screening of patients should be performed to prevent future consequences such as kidney transplant rejection during of dialysis.
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22
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Märtson AG, Sturkenboom MGG, Knoester M, van der Werf TS, Alffenaar JWC, Hope W. Standard ganciclovir dosing results in slow decline of cytomegalovirus viral loads. J Antimicrob Chemother 2022; 77:466-473. [PMID: 35107143 PMCID: PMC8809194 DOI: 10.1093/jac/dkab419] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/14/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) can cause severe disease, including rejection in transplant recipients. Ganciclovir and its oral prodrug valganciclovir have been used as first-line therapy for CMV disease in transplant recipients. The exposure targets of ganciclovir are not exactly known, and toxicity and resistance have interfered with ganciclovir therapy. OBJECTIVES To evaluate the pharmacokinetics (PK) and pharmacodynamics (PD) of ganciclovir in transplant recipients. METHODS We used patient data from a previous observational study on ganciclovir therapeutic drug monitoring (TDM) in prophylaxis and therapy. The ganciclovir concentrations and CMV viral loads were determined during routine clinical care. The PK/PD population modelling and simulations were done with non-parametric methodology using the Pmetrics program. RESULTS Eighty-five patients were included in the PK modelling. The final PK model was a two-compartment model with first-order absorption and elimination. A subset of 17 patients on CMV therapy were included in the PD modelling. A median of 4 (range 2-8) viral loads were obtained per patient. A simulation of 10 000 patients showed that an approximately 1 log10 reduction of CMV viral load will be observed after 12.5 days at the current recommended dose. CONCLUSIONS The developed linked PK/PD population model and subsequent PD simulations showed slow decline of CMV viral load and it appears that dosing of (val)ganciclovir in this study might have been inadequate to achieve fast reduction of viral load. It is clear that further studies are needed to specify the PD effects of ganciclovir by performing systematic measurements of both ganciclovir concentrations and CMV viral loads.
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Affiliation(s)
- Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marieke G G Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marjolein Knoester
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tjip S van der Werf
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Westmead Hospital, Westmead, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, New South Wales, Australia
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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23
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Luyt CE, Hékimian G, Bréchot N, Chastre J. Viral Ventilator-Associated Pneumonia/Hospital-Acquired Pneumonia. Semin Respir Crit Care Med 2022; 43:310-318. [PMID: 35100650 DOI: 10.1055/s-0041-1740981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Among the viruses possibly responsible for hospital-acquired and ventilator-associated pneumonia, herpes simplex virus (HSV) is probably the most often involved: HSV reactivation is frequent in intensive care unit patients, and lung parenchymal infection (HSV bronchopneumonitis) has been well described, either using cytological signs of parenchymal involvement in cells obtained during bronchoalveolar lavage or using HSV virus load in the lower respiratory tract. Although treating patients with HSV bronchopneumonitis may be recommended, based on expert opinion, prophylactic or preemptive treatment of HSV reactivation should be avoided. Ventilator-associated pneumonia due to cytomegalovirus (CMV) is less frequent than HSV bronchopneumonitis, and more difficult to diagnose. No data exists on the impact of antiviral treatment on CMV pneumonia. The involvement of respiratory viruses has been described in patients with healthcare-associated pneumonia and hospital-acquired pneumonia, but their role in ventilator-associated pneumonia is not clear.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris.,INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris.,INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris
| | - Nicolas Bréchot
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris.,INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris
| | - Jean Chastre
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris.,INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris
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24
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Abstract
Reactivation of herpsviruses, mainly HSV, CMV and EBV, are frequent among critically ill patients. Although they are not immunocompromised from a classical point of view, these patients often present an alteration of their immune system favoring viral reactivation. Seropositive patients with sepsis and under mechanical ventilation are particularly at risk. Herpesviruses have a pulmonary tropism and can be responsible for non-resolving forms of acute respiratory distress syndrome with high mortality. However, the direct causality between herpesviruses reactivation and impaired outcomes among severely ill patients remains under debate.
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25
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Khan MM, Ali MJ, Hanif H, Maqsood MH, Ahmad I, Alvarez JEG, Catana MA, Lau DTY. OUP accepted manuscript. Gastroenterol Rep (Oxf) 2022; 10:goac018. [PMID: 35663152 PMCID: PMC9154071 DOI: 10.1093/gastro/goac018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/04/2022] [Accepted: 04/24/2022] [Indexed: 11/25/2022] Open
Abstract
Hepatitis B virus (HBV) remains a global public health problem despite the availability of effective vaccine and antiviral therapy. Cytomegalovirus (CMV), another hepatotropic virus, is also very prevalent in the general population worldwide. Both HBV and CMV can persist in the host and have potential to reactivate especially with weakened host cellular immunity. Superimposed CMV infection can lead to severe HBV reactivation. The pathogenesis of the co-infection of HBV and CMV remains poorly understood. Studies reported conflicting results regarding the inhibitory effect of CMV on HBV replication. There is an unmet need on the management of co-infection of HBV and CMV; research initiatives dedicated to understanding their interactions are urgently needed.
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Affiliation(s)
- Muzammil M Khan
- Department of Medicine, Division of Gastroenterology, Liver Research Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mukarram J Ali
- Department of Medicine, Division of Gastroenterology, Liver Research Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hira Hanif
- Department of Medicine, Division of Gastroenterology, Liver Research Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Muhammad H Maqsood
- Department of Medicine, Division of Gastroenterology, Liver Research Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Imama Ahmad
- Department of Medicine, North Shore Medical Center, Salem, MA, USA
| | - Javier E G Alvarez
- Department of Medicine, Division of Gastroenterology, Liver Research Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Maria-Andreea Catana
- Department of Medicine, Division of Gastroenterology, Liver Research Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daryl T Y Lau
- Department of Medicine, Division of Gastroenterology, Liver Research Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Corresponding author. Department of Medicine, Liver Research Center, 110 Francis Street, Suite 4A, Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA. Tel: +1 (617) 632-1070; Fax: (617) 632-1065;
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26
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Bai G, Cui N, Wang H, Cheng W, Han W, Chen J, Guo Y, Wang F. T-lymphocyte subtyping: an early warning and a potential prognostic indicator of active cytomegalovirus infection in patients with sepsis. Immunol Cell Biol 2022; 100:777-790. [PMID: 36106958 PMCID: PMC9828035 DOI: 10.1111/imcb.12586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 01/12/2023]
Abstract
Cytomegalovirus (CMV) infection is very common in patients suffering from sepsis and may cause poor prognosis. To explore the relationship between immune status of patients with sepsis and CMV infection, we assessed T lymphocyte subtyping and other commonly used clinical parameters in patients with sepsis upon admission to the intensive care unit (ICU) and evaluated their potential impact on diagnosis and outcomes of active CMV infection. In our study, 82 of 599 patients with sepsis were diagnosed with active CMV infection. The 28-day mortality was higher in active CMV-infected than nonactive CMV-infected patients (20.7% versus 9.9%); 51of 82 active CMV-infected patients with sepsis were assessed to have CMV-DNA-negative conversion, while 31 were persistently positive for CMV DNA. Higher CD8+ CD28+ T-cell counts at presentation were associated with CMV-DNA-negative conversion and lower 28-day mortality. The CMV-DNA-negative conversion and 28-day mortality of active CMV-infected patients with sepsis could be predicted using cutoff values of 151 (74.5% sensitivity and 87.1% specificity) and 64.5 (52.9% sensitivity and 92.3% specificity) CD8+ CD28+ T cells mL-1 at ICU admission, respectively. Higher CD8+ CD28+ T-cell count was significantly associated with active CMV infection, higher CMV-DNA-negative conversion and lower 28-day mortality, which may be a potential marker for early warning of active CMV infection and outcome prediction.
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Affiliation(s)
- Guangxu Bai
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina,Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Na Cui
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina,Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina,Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical ScienceBeijingChina
| | - Hao Wang
- Department of Critical Care MedicineBeijing Jishuitan HospitalBeijingChina
| | - Wei Cheng
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina,Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Wen Han
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina,Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Jianwei Chen
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina,Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Ye Guo
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical ScienceBeijingChina
| | - Fei Wang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical ScienceBeijingChina
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27
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Mozafarybazargany M, Khoshsirat NA. Severe cytomegalovirus encephalitis in an immunocompetent healthy young woman: A case report. IDCases 2022; 27:e01403. [PMID: 35070720 PMCID: PMC8763626 DOI: 10.1016/j.idcr.2022.e01403] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/12/2022] [Accepted: 01/12/2022] [Indexed: 12/09/2022] Open
Abstract
Cytomegalovirus (CMV) causes a mild illness in immunocompetent patients. Conversely, it can be life-threatening in immunocompromised or critically ill patients. We present a 48-year-old immunocompetent woman presenting primary severe CMV encephalitis. She presented with a headache, fever, and drowsiness. She did not respond to empirical treatment. Her level of consciousness deteriorated, she was put on mechanical ventilation on day two. Bacterial culture, herpes simplex virus, and tuberculosis were negative in cerebrospinal fluid (CSF). After three weeks, the patient was transferred to our center due to financial matters. Brain magnetic resonance imaging (MRI) showed diffuse hydrocephalus, periventricular T2 hyperintensity, patchy basal ganglia, and diffuse leptomeningeal enhancement. CMV polymerase chain reaction (PCR) was positive in cerebrospinal fluid (CSF) specimen. Ganciclovir (5 mg/kg/IV q12h) was initiated. Subsequently, a brain shunt was inserted. Her level of consciousness raised, she was weaned from the ventilator. She was discharged after 52 days in a bedridden state, quadriplegic, and only able to speak words with a minor swallowing problem. She remained in the same condition for one year. She was expired one year later due to aspiration pneumonia after four weeks of hospitalization. Early diagnosis and treatment of severe CMV encephalitis are crucial to prevent neurological sequelae.
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28
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Mallet F, Diouf L, Meunier B, Perret M, Reynier F, Leissner P, Quemeneur L, Griffiths AD, Moucadel V, Pachot A, Venet F, Monneret G, Lepape A, Rimmelé T, Tan LK, Brengel-Pesce K, Textoris J. Herpes DNAemia and TTV Viraemia in Intensive Care Unit Critically Ill Patients: A Single-Centre Prospective Longitudinal Study. Front Immunol 2021; 12:698808. [PMID: 34795661 PMCID: PMC8593420 DOI: 10.3389/fimmu.2021.698808] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 10/12/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction We analysed blood DNAemia of TTV and four herpesviruses (CMV, EBV, HHV6, and HSV-1) in the REAnimation Low Immune Status Marker (REALISM) cohort of critically ill patients who had presented with either sepsis, burns, severe trauma, or major surgery. The aim was to identify common features related to virus and injury-associated pathologies and specific features linking one or several viruses to a particular pathological context. Methods Overall and individual viral DNAemia were measured over a month using quantitative PCR assays from the 377 patients in the REALISM cohort. These patients were characterised by clinical outcomes [severity scores, mortality, Intensive Care Unit (ICU)-acquired infection (IAI)] and 48 parameters defining their host response after injury (cell populations, immune functional assays, and biomarkers). Association between viraemic event and clinical outcomes or immune markers was assessed using χ2-test or exact Fisher’s test for qualitative variables and Wilcoxon test for continuous variables. Results The cumulative incidence of viral DNAemia increased from below 4% at ICU admission to 35% for each herpesvirus during the first month. EBV, HSV1, HHV6, and CMV were detected in 18%, 12%, 10%, and 9% of patients, respectively. The incidence of high TTV viraemia (>10,000 copies/ml) increased from 11% to 15% during the same period. Herpesvirus viraemia was associated with severity at admission; CMV and HHV6 viraemia correlated with mortality during the first week and over the month. The presence of individual herpesvirus during the first month was significantly associated (p < 0.001) with the occurrence of IAI, whilst herpesvirus DNAemia coupled with high TTV viraemia during the very first week was associated with IAI. Herpesvirus viraemia was associated with a lasting exacerbated host immune response, with concurrent profound immune suppression and hyper inflammation, and delayed return to immune homeostasis. The percentage of patients presenting with herpesvirus DNAemia was significantly higher in sepsis than in all other groups. Primary infection in the hospital and high IL10 levels might favour EBV and CMV reactivation. Conclusion In this cohort of ICU patients, phenotypic differences were observed between TTV and herpesviruses DNAemia. The higher prevalence of herpesvirus DNAemia in sepsis hints at further studies that may enable a better in vivo understanding of host determinants of herpesvirus viral reactivation. Furthermore, our data suggest that EBV and TTV may be useful as additional markers to predict clinical deterioration in ICU patients.
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Affiliation(s)
- François Mallet
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Léa Diouf
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France.,IVIDATA, Levallois-Perret, France
| | - Boris Meunier
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France.,Soladis Inc., Cambridge, MA, United States
| | - Magali Perret
- BIOASTER Technology Research Institute, Lyon, France
| | | | | | | | - Andrew D Griffiths
- Laboratoire de Biochimie (LBC), École Supérieure de Physique et de Chimie Industrielles de la ville de Paris (ESPCI) Paris, Paris Sciences & Lettres (PSL) Université, Centre National de la Recherche Scientifique (CNRS) UMR8231, Paris, France
| | - Virginie Moucadel
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Alexandre Pachot
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Fabienne Venet
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Guillaume Monneret
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Alain Lepape
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Thomas Rimmelé
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | | | - Karen Brengel-Pesce
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Julien Textoris
- EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1-Hospices Civils de Lyon-bioMérieux), Joint Research Unit HCL-bioMérieux, Immunology Laboratory & Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
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29
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Zhang Z, Liu X, Sang L, Chen S, Wu Z, Zhang J, Sun Y, Huang Y, Xu Y, He W, Li Y, Liu X. Cytomegalovirus reactivation in immunocompetent mechanical ventilation patients: a prospective observational study. BMC Infect Dis 2021; 21:1026. [PMID: 34592936 PMCID: PMC8482357 DOI: 10.1186/s12879-021-06698-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/15/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) reactivation is associated with adverse prognoses of critically ill patients. However, the epidemiology and predictors of CMV reactivation in immunocompetent patients receiving mechanical ventilation (MV) are not clear. The aim of this study was to investigate the epidemiology and predictors of CMV reactivation in immunocompetent patients requiring MV. METHODS A single-center, prospective observational study (conducted from June 30, 2017 to July 01, 2018) with a follow-up of 90 days (September 29, 2018) that included 71 CMV-seropositive immunocompetent patients with MV at a 37-bed university hospital general intensive care unit (ICU) in China. Routine detection of CMV DNAemia was performed once a week for 28 days (Days 1, 7, 14, 21, and 28). CMV serology, laboratory findings, and clinical data were obtained during hospitalization. RESULTS Among 71 patients, 13 (18.3%) showed CMV reactivation within 28 days in the ICU. The median time to reactivation was 7 days. CMV reactivation was related to various factors, including body mass index (BMI), sepsis, N-terminal pro-b-type natriuretic peptide (NT-proBNP), blood urea nitrogen (BUN), and hemoglobin (Hb) levels (P < 0.05). In the multivariate regression model, BMI, Hb level, and sepsis were independently associated with CMV reactivation patients (P < 0.05). Moreover, the area under the receiver operating characteristic (AUROC) of BMI, Hb, and BMI combined with Hb was 0.69, 0.70, and 0.76, respectively. The duration of MV, hospitalization expense, length of ICU stay, and 90 day all-cause mortality rate in patients with CMV reactivation was significantly higher than in those without CMV reactivation (P < 0.05). CONCLUSIONS Among immunocompetent patients with MV, the incidence of CMV reactivation was 18.3%. CMV reactivation was associated with several adverse prognoses. BMI, Hb, and sepsis were independent risk factors for CMV reactivation. BMI and Hb may predict CMV reactivation.
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Affiliation(s)
- Zhihui Zhang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.,Guangzhou Medical University, Guangzhou, Guangdong, 511436, People's Republic of China
| | - Xuesong Liu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Ling Sang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Sibei Chen
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Zhan Wu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.,Guangzhou Medical University, Guangzhou, Guangdong, 511436, People's Republic of China
| | - Jierong Zhang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.,Guangzhou Medical University, Guangzhou, Guangdong, 511436, People's Republic of China
| | - Yining Sun
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.,Guangzhou Medical University, Guangzhou, Guangdong, 511436, People's Republic of China
| | - Yongbo Huang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Yonghao Xu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Weiqun He
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Yimin Li
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Xiaoqing Liu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.
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30
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Kumru Sahin G, Eyupoglu S, Eren Sadioglu R, Cinar G, Ates K, Erturk S, Nergizoglu G, Sengul S, Kutlay S, Keven K. Cytomegalovirus infection in patients with glomerular diseases treated with cyclophosphamide: a single-center prospective study. Int Urol Nephrol 2021; 54:1091-1096. [PMID: 34398345 DOI: 10.1007/s11255-021-02973-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 08/02/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Cytomegalovirus infection is an important complication in immunocompromised patients. As few studies have shown that cyclophosphamide treatment is a risk factor for cytomegalovirus infection in patients with glomerulonephritis, we aimed to describe the frequency and risk factors of cytomegalovirus infection in glomerulonephritis patients treated with cyclophosphamide. METHODS We prospectively recruited 43 cytomegalovirus seropositive patients with glomerulonephritis treated with cyclophosphamide. We screened all patients for viral DNA monthly during treatment. Patients were compared for age, sex, glomerular pathology, renal function and clinical status regarding development of cytomegalovirus infection before and after the treatment. RESULTS Cytomegalovirus infection was detected in 10 (23.3%) patients, most commonly within the first 2 months of cyclophosphamide treatment. All patients recovered without any cytomegalovirus-related complications. Patients with cytomegalovirus infection had higher serum creatinine (4.2 ± 3.2 vs. 1.9 ± 1.8 mg/dl, p = 0.006) and lower estimated glomerular filtration rate (29 ± 11 vs. 65 ± 8 ml/min/1.73 m2, p = 0.016) at diagnosis compared with cytomegalovirus infection non-occurred patients. In addition, number of patients presented with rapidly progressive glomerulonephritis were higher in cytomegalovirus infection group (80.0% vs. 27.3%, p = 0.007). Moreover, cytomegalovirus infection was associated with prolonged hospital stay (54 ± 7 vs. 29 ± 6 days, p = 0.027). CONCLUSION Cytomegalovirus infection is a common complication in glomerulonephritis patients treated with cyclophosphamide in this prospective study. Routine monitoring and prophylaxis should be considered for these high-risk patients.
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Affiliation(s)
- Gizem Kumru Sahin
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey. .,Department of Nephrology, Ministry of Health Van Education Research Hospital, Van, Turkey.
| | - Sahin Eyupoglu
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | | | - Gule Cinar
- Department of Infectious Disease and Clinical Microbiology, Ankara University School of Medicine, Ankara, Turkey
| | - Kenan Ates
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Sehsuvar Erturk
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Gokhan Nergizoglu
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Sule Sengul
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Sim Kutlay
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Kenan Keven
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
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31
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Schouten J, De Waele J, Lanckohr C, Koulenti D, Haddad N, Rizk N, Sjövall F, Kanj SS. Antimicrobial stewardship in the ICU in COVID times: the known unknowns. Int J Antimicrob Agents 2021; 58:106409. [PMID: 34339777 PMCID: PMC8323503 DOI: 10.1016/j.ijantimicag.2021.106409] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/14/2021] [Accepted: 07/23/2021] [Indexed: 01/08/2023]
Abstract
Since the start of the COVID-19 pandemic, there has been concern about the concomitant rise of antimicrobial resistance. While bacterial co-infections seem rare in COVID-19 patients admitted to hospital wards and intensive care units (ICUs), an increase in empirical antibiotic use has been described. In the ICU setting, where antibiotics are already abundantly—and often inappropriately—prescribed, the need for an ICU-specific antimicrobial stewardship programme is widely advocated. Apart from essentially warning against the use of antibacterial drugs for the treatment of a viral infection, other aspects of ICU antimicrobial stewardship need to be considered in view of the clinical course and characteristics of COVID-19. First, the distinction between infectious and non-infectious (inflammatory) causes of respiratory deterioration during an ICU stay is difficult, and the much-debated relevance of fungal and viral co-infections adds to the complexity of empirical antimicrobial prescribing. Biomarkers such as procalcitonin for the decision to start antibacterial therapy for ICU nosocomial infections seem to be more promising in COVID-19 than non-COVID-19 patients. In COVID-19 patients, cytomegalovirus reactivation is an important factor to consider when assessing patients infected with SARS-CoV-2 as it may have a role in modulating the patient immune response. The diagnosis of COVID-19-associated invasive aspergillosis is challenging because of the lack of sensitivity and specificity of the available tests. Furthermore, altered pharmacokinetic/pharmacodynamic properties need to be taken into account when prescribing antimicrobial therapy. Future research should now further explore the ‘known unknowns’, ideally with robust prospective study designs.
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Affiliation(s)
- Jeroen Schouten
- Department of Intensive care, Radboudumc, Nijmegen, The Netherlands.
| | - Jan De Waele
- Department of Intensive Care, UZ Gent, Gent, Belgium
| | - Christian Lanckohr
- Antibiotic Stewardship Team, Institut für Hygiene, Universitätsklinikum Münster, Germany
| | - Despoina Koulenti
- Critical Care Department, 'Attiko' University Hospital, Athens, Greece; UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Nisrine Haddad
- Division of Infectious Diseases, American University of Beirut Medical Center, Lebanon
| | - Nesrine Rizk
- Division of Infectious Diseases, American University of Beirut Medical Center, Lebanon
| | - Fredrik Sjövall
- Department of Intensive care, Skane University Hospital, Malmö, Sweden
| | - Souha S Kanj
- Division of Infectious Diseases, American University of Beirut Medical Center, Lebanon
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Wamalwa D, Njuguna I, Maleche-Obimbo E, Begnel E, Chebet DJ, Onyango JA, Cranmer LM, Huang ML, Richardson BA, Boeckh M, John-Stewart G, Slyker J. Cytomegalovirus viremia and clinical outcomes in Kenyan children diagnosed with HIV in hospital. Clin Infect Dis 2021; 74:1237-1246. [PMID: 34214163 DOI: 10.1093/cid/ciab604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) viremia is common in HIV infection, and is associated with worse long-term outcomes. To date, no studies have assessed CMV viremia in children diagnosed with HIV in hospital. METHODS We studied CMV viremia and clinical outcomes in 163 Kenyan children aged 2 months-12 years, diagnosed with HIV in hospital. CMV DNA levels in plasma were measured using quantitative PCR. Regression models were used to assess associations between CMV viremia >1000 IU/mL and the risk of continued hospitalization or death at 15 days, duration of hospitalization, and 6-month mortality. RESULTS At enrollment, 62/114 (54%) children had CMV viremia, and 20 (32%) were >1000 IU/mL. Eleven CMV reactivations were observed after admission. The prevalence and level of CMV viremia were highest in children <2 years and lowest in children >5 years old. CMV viremia >1000 IU/mL was independently associated with age < 2 years (p=0.03), higher log10 HIV RNA level (p=0.01), and height-for-age z score <-2 (p=0.02). Adjusting for age and log10 HIV RNA, the relative risk of death or continued hospitalization at 15 days was 1.74 (95%CI=1.04, 2.90), and the hazard ratio of 6-month mortality was 1.97 (95%CI=0.57, 5.07) for children with CMV DNA ≥1000 IU/ml compared to lower-level or undetectable CMV DNA. Children with CMV DNA ≥1000 IU/ml were hospitalized a median ~5 days longer than children with lower-level or undetectable CMV DNA (p=0.002). CONCLUSIONS In this nested observational study, CMV viremia was common in hospitalized children with HIV, and levels ≥1000 IU/mL were associated with increased risk of mortality and longer hospitalization.
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Affiliation(s)
- Dalton Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Irene Njuguna
- Kenyatta National Hospital, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, Washington, United States
| | | | - Emily Begnel
- Department of Global Health, University of Washington, Seattle, Washington, United States
| | - Daisy J Chebet
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Judith A Onyango
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Lisa Marie Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Meei-Li Huang
- Departments of Laboratory Medicine and Virology, Department of Global Health, University of Washington, Seattle, Washington, United States
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, United States.,Department of Biostatistics, University of Washington, Seattle, Washington, United States.,Vaccine and Infectious Disease Division, Fred Hutch, Seattle, Washington, United States
| | - Michael Boeckh
- Vaccine and Infectious Disease Division, Fred Hutch, Seattle, Washington, United States.,Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Grace John-Stewart
- Kenyatta National Hospital, Nairobi, Kenya.,Department of Epidemiology, University of Washington, Seattle, Washington, United States.,Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Jennifer Slyker
- Kenyatta National Hospital, Nairobi, Kenya.,Department of Epidemiology, University of Washington, Seattle, Washington, United States
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SARS-CoV-2 and Cytomegalovirus Co-Infections-A Case Series of Critically Ill Patients. J Clin Med 2021; 10:jcm10132792. [PMID: 34201947 PMCID: PMC8268027 DOI: 10.3390/jcm10132792] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 02/07/2023] Open
Abstract
The SARS-CoV-2 pandemic has placed great strain on the most developed of health care systems, especially in the context of critical care. Although co-infections with cytomegalovirus (CMV) are frequent in the critically ill due to underlying immune suppression of multiple causes, the impact on COVID-19 patients remains unclear. Furthermore, severe COVID-19 has recently been associated with significant immune suppression, and this may in turn impact CMV reactivation, possibly contributing to clinical course. Nevertheless, multiple confounding factors in these patients will certainly challenge upcoming research. The authors present a case series of five patients admitted to the intensive care unit (ICU) in the context of respiratory failure due to severe COVID-19. All patients evolved with CMV reactivation during ICU stay.
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Yaiw KC, Mohammad AA, Taher C, Cui HL, Costa H, Kostopoulou ON, Jung M, Assinger A, Wilhelmi V, Yang J, Strååt K, Rahbar A, Pernow J, Söderberg-Nauclér C. Human Cytomegalovirus Reduces Endothelin-1 Expression in Both Endothelial and Vascular Smooth Muscle Cells. Microorganisms 2021; 9:microorganisms9061137. [PMID: 34070407 PMCID: PMC8229579 DOI: 10.3390/microorganisms9061137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/16/2022] Open
Abstract
Human cytomegalovirus (HCMV) is an opportunistic pathogen that has been implicated in the pathogenesis of atherosclerosis. Endothelin-1 (ET-1), a potent vasoconstrictive peptide, is overexpressed and strongly associated with many vasculopathies. The main objective of this study was to investigate whether HCMV could affect ET-1 production. As such, both endothelial and smooth muscle cells, two primary cell types involved in the pathogenesis of atherosclerosis, were infected with HCMV in vitro and ET-1 mRNA and proteins were assessed by quantitative PCR assay, immunofluorescence staining and ELISA. HCMV infection significantly decreased ET-1 mRNA and secreted bioactive ET-1 levels from both cell types and promoted accumulation of the ET-1 precursor protein in infected endothelial cells. This was associated with inhibition of expression of the endothelin converting enzyme-1 (ECE-1), which cleaves the ET-1 precursor protein to mature ET-1. Ganciclovir treatment did not prevent the virus suppressive effects on ET-1 expression. Consistent with this observation we identified that the IE2-p86 protein predominantly modulated ET-1 expression. Whether the pronounced effects of HCMV in reducing ET-1 expression in vitro may lead to consequences for regulation of the vascular tone in vivo remains to be proven.
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Affiliation(s)
- Koon-Chu Yaiw
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
- Correspondence: (K.-C.Y.); (C.S.-N.)
| | - Abdul-Aleem Mohammad
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Chato Taher
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Huanhuan Leah Cui
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Helena Costa
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Ourania N. Kostopoulou
- Department of Oncology and Pathology, Karolinska Institutet, SE 171 64 Stockholm, Sweden;
| | - Masany Jung
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Alice Assinger
- Institute of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Medical University of Vienna, A-1090 Vienna, Austria;
| | - Vanessa Wilhelmi
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Jiangning Yang
- Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital Solna, SE 171 64 Stockholm, Sweden; (J.Y.); (J.P.)
| | - Klas Strååt
- Department of Medicine, Division of Hematology, BioClinicum and Centre for Molecular Medicine, Karolinska University, Hospital Solna and Karolinska Institutet, SE 171 64 Stockholm, Sweden;
| | - Afsar Rahbar
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - John Pernow
- Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital Solna, SE 171 64 Stockholm, Sweden; (J.Y.); (J.P.)
| | - Cecilia Söderberg-Nauclér
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
- Correspondence: (K.-C.Y.); (C.S.-N.)
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Stadnik CMB, Caurio CFB, Rodrigues-Filho EM, Nedel WL, Cantisani GPC, Zanotelli ML, Pasqualotto AC. Impact of cytomegalovirus reactivation just before liver transplantation: A prospective cohort study. World J Gastrointest Pathophysiol 2021; 12:51-58. [PMID: 34084592 PMCID: PMC8160598 DOI: 10.4291/wjgp.v12.i3.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/30/2020] [Accepted: 02/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) is the most common viral pathogen after liver transplantation (LT). Although reactivation of CMV infection is generally described in the context of immunosuppression, it has also been described in critically ill immunocompetent patients including cirrhotic patients.
AIM To determine the incidence of reactivated CMV prior to LT.
METHODS This was a prospective cohort study evaluating adult patients who underwent LT between 2014 and 2016. A plasma sample was obtained from all patients for CMV quantitative real-time PCR testing right before transplantation. Patients were followed for at least 1 year to assess the following outcomes: Incidence of CMV infection, organ rejection and overall mortality.
RESULTS A total of 72 patients were enrolled. Four patients died before transplantation, thus 68 patients were followed up for a median of 44 mo (20-50 mo). In 23/72 patients (31.9%) CMV was reactivated before transplantation. Post-transplantation, 16/68 (23.5%) patients had CMV infection and that was significantly associated with the recipient being CMV negative and a CMV-positive donor. Pre-transplant CMV reactivation was not associated with overall mortality (log rank: 0.9).
CONCLUSION This study shows that CMV infection is common in patients with chronic liver disease just before LT, but the clinical impact of this infection seems to be negligible.
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Affiliation(s)
- Claudio Marcel B Stadnik
- Infection Control Department, Santa Casa de Misericordia de Porto Alegre, Porto Alegre 90075075, RS, Brazil
| | - Cassia Ferreira B Caurio
- Molecular Biology Laboratory, Santa Casa de Misericordia de Porto Alegre, Porto Alegre 90075075, RS, Brazil
| | | | - Wagner L Nedel
- Intensive Care, Santa Casa de Misericordia de Porto Alegre, Porto Alegre 90075075, RS, Brazil
| | - Guido PC Cantisani
- Liver Transplant Unit, Santa Casa de Misericordia de Porto Alegre, Porto Alegre 90075075, RS, Brazil
| | - Maria L Zanotelli
- Liver Transplant Unit, Santa Casa de Misericordia de Porto Alegre, Porto Alegre 90075075, RS, Brazil
| | - Alessandro C Pasqualotto
- Molecular Biology Laboratory, Santa Casa de Misericordia de Porto Alegre, Porto Alegre 90075075, RS, Brazil
- Infectious Diseases Unit, Universidade Federal de Ciencias da Saude de Porto Alegre, Porto Alegre 90035075, RS, Brazil
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36
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Leemans S, Maillart E, Van Noten H, Oliveira Dos Santos L, Leahu LM, Kamgang P, Gallerani A, Clevenbergh P. Cytomegalovirus haemorrhagic colitis complicating COVID-19 in an immunocompetent critically ill patient: A case report. Clin Case Rep 2021; 9:e03600. [PMID: 34084470 PMCID: PMC8142309 DOI: 10.1002/ccr3.3600] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/05/2020] [Accepted: 11/08/2020] [Indexed: 12/23/2022] Open
Abstract
Suspicion threshold for opportunistic coinfections should be lowered in severe COVID-19. Serum CMV polymerase chain reaction and colonoscopy should be discussed in presence of persistent digestive disturbances.
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Affiliation(s)
- Sophie Leemans
- Department of Infectious DiseasesCentre Hospitalier Universitaire BrugmannBrusselsBelgium
| | - Evelyne Maillart
- Department of Infectious DiseasesCentre Hospitalier Universitaire BrugmannBrusselsBelgium
| | - Héloïse Van Noten
- Department of Infectious DiseasesCentre Hospitalier Universitaire BrugmannBrusselsBelgium
| | | | - Laura Maria Leahu
- Department of Physical and Rehabilitation MedicineCentre Hospitalier Universitaire BrugmannBrusselsBelgium
| | - Prochore Kamgang
- Department of Internal MedicineCentre Hospitalier Universitaire BrugmannBrusselsBelgium
| | - Andrea Gallerani
- Department of Intensive Care MedicineCentre Hospitalier Universitaire BrugmannBrusselsBelgium
| | - Philippe Clevenbergh
- Department of Infectious DiseasesCentre Hospitalier Universitaire BrugmannBrusselsBelgium
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Clinical Features, Endoscopic Findings, and Predictive Factors for Mortality in Tissue-Invasive Gastrointestinal Cytomegalovirus Disease between Immunocompetent and Immunocompromised Patients. Gastroenterol Res Pract 2021; 2021:8886525. [PMID: 33897776 PMCID: PMC8052155 DOI: 10.1155/2021/8886525] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 03/19/2021] [Accepted: 03/27/2021] [Indexed: 12/26/2022] Open
Abstract
Background and Aims Tissue-invasive gastrointestinal cytomegalovirus (TI-GI CMV) disease is common in immunocompromised patients, but the increasing prevalence in immunocompetent patients has been reported. This study compared the clinical manifestations, endoscopic features, treatment outcomes, and predictors for inhospital mortality of TI-GI CMV between immunocompromised and immunocompetent patients. Methods Patients with HIV infection, malignancy, or receiving immunosuppressive agents (chemotherapy, high dose, or long-term corticosteroids) were defined as the immunocompromised group. Demographic and inhospital mortality data were obtained and retrospectively analyzed. Results A total of 213 patients (89 immunocompetent) with histologically confirmed TI-GI CMV were enrolled. Immunocompetent patients were older (70 vs. 52 years; p < 0.001), had more GI bleeding as a presenting symptom (47.2% vs. 29.0%; p = 0.010), and shorter symptom onset (2 vs. 14 days, p = 0.018). Concomitant extra-GI involvement was only seen in the immunocompromised group (6.5% vs. 0%; p = 0.02). Diffuse GI tract (14.5% vs. 4.5%; p = 0.032) and esophageal involvement (14.5% vs. 5.6%; p = 0.046) were more frequent in the immunocompromised, while small bowel involvement was more frequent in the immunocompetent group (19.1% vs. 8.1%; p = 0.029). An overall inhospital mortality was 27.7%. There was no significant difference in inhospital survival probability between the two groups (Peto-Peto test, p = 0.65). ICU admission (hazard ratio [HR] 7.21; 95% CI 2.55-20.36), sepsis or shock (HR 1.98; 95% CI 1.08-3.66), malnutrition (HR 2.62; 95% CI 1.05-7.01), and receiving chemotherapy (HR 5.2; 95% CI 1.89-14.29) were independent factors for inhospital mortality. Antiviral treatment for more than 14 days was the only protective factor to improve survival (Peto-Peto test, p < 0.001). Conclusions Immunocompetent and immunocompromised patients with TI-GI CMV disease had distinct clinical and endoscopic characteristics. There was no significant difference in the inhospital mortality between the two groups. The factors for mortality were ICU admission, sepsis/shock, malnutrition, and receiving chemotherapy. Early diagnosis and initiation of antiviral treatment might improve the survival probability.
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Söderberg-Nauclér C. Does reactivation of cytomegalovirus contribute to severe COVID-19 disease? IMMUNITY & AGEING 2021; 18:12. [PMID: 33712035 PMCID: PMC7952506 DOI: 10.1186/s12979-021-00218-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/04/2021] [Indexed: 02/07/2023]
Abstract
The majority of people infected with SARS-CoV-2 are asymptomatic or have mild to moderate symptoms. However, for unknown reasons, about 15 % have severe pneumonia requiring hospital care and oxygen support, and about 5 % develop acute respiratory distress syndrome, septic shock, and multiorgan failure that result in a high mortality rate. The risk of severe COVID-19 is highest among those who are over 70 years of age. Why severe COVID-19 develops in some people but not others is not understood. Could some cases involve reactivation of latent cytomegalovirus (CMV)?
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Affiliation(s)
- Cecilia Söderberg-Nauclér
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, and Division of Neurology, Karolinska University Hospital, Bioclinicum, Visionsgatan 4, 171 64, Solna, Stockholm, Sweden.
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Yang SL, Lin TW, Lin HC, Wang HY, Chang PY, Wang PN, Yang S, Lu JJ. Molecular Epidemiology of Cytomegalovirus UL97 and UL54 variants in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:971-978. [PMID: 33632621 DOI: 10.1016/j.jmii.2021.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/16/2021] [Accepted: 01/25/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The antiviral resistance of cytomegalovirus (CMV) infections is associated with mutations in the CMV UL54 and UL97 gene regions and is a serious problem in immunocompromised patients. However, the molecular epidemiology of UL54 and UL97 in Taiwan is unclear. METHODS We conducted a retrospective study of patients with CMV infections between January and December 2016 in two tertiary hospitals, one regional hospital in Taiwan. CMV DNAemia was confirmed by elevated CMV DNA titers. Then the regions of the UL54 and UL97 mutations were amplified by PCR and sequenced. RESULTS Of 729 patients with CMV syndrome, 112 CMV DNAemia patients were enrolled. Twelve novel variants in UL54 (P342S, S384F, K434R, S673F, T754M, R778H, C814S, M827I, G878E, S880L, E888K, and S976N) and one novel variant in UL97 (M615T) were discovered. UL97 antiviral resistance mutations (L595S, M460I, and M460V) were found in four patients (3.6%). In the drug resistance strains, the mutation events occurred after 83-150 days of therapy, and drug resistance was also observed in these patients. The following high frequency variants were observed: D605E in UL97 and A885T, N898D, V355A, N685S, and A688V in UL54. CONCLUSION The results demonstrate that the positive rate of CMV DNAemia was 15.3% (112/729) among the patients with clinical CMV infection symptoms. The proportion of antiviral resistance CMV strains within CMV DNAemia patients was 3.6%. With the information of polymorphism incidence in the UL54 and UL97 patients from our study, determination of the genetic profile of UL54 and UL97 among immunocompromised populations with refractory CMV infection is recommended.
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Affiliation(s)
- Shu-Li Yang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
| | - Ting-Wei Lin
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsin-Chieh Lin
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsin-Yao Wang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Ph.D. Program in Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Pi-Yueh Chang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Po-Nan Wang
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Internal Medicine, Division of Hematology and Oncology, Chang Gung Memorial Hospital, Taoyun, Taiwan
| | - Shuan Yang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jang-Jih Lu
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Papazian L, Jaber S, Hraiech S, Baumstarck K, Cayot-Constantin S, Aissaoui N, Jung B, Leone M, Souweine B, Schwebel C, Bourenne J, Allardet-Servent J, Kamel T, Lu Q, Zandotti C, Loundou A, Penot-Ragon C, Chastre J, Forel JM, Luyt CE. Preemptive ganciclovir for mechanically ventilated patients with cytomegalovirus reactivation. Ann Intensive Care 2021; 11:33. [PMID: 33570708 PMCID: PMC7876264 DOI: 10.1186/s13613-020-00793-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022] Open
Abstract
Background The effect of cytomegalovirus (CMV) reactivation on the length of mechanical ventilation and mortality in immunocompetent ICU patients requiring invasive mechanical ventilation remains controversial. The main objective of this study was to determine whether preemptive intravenous ganciclovir increases the number of ventilator-free days in patients with CMV blood reactivation. Methods This double-blind, placebo-controlled, randomized clinical trial involved 19 ICUs in France. Seventy-six adults ≥ 18 years old who had been mechanically ventilated for at least 96 h, expected to remain on mechanical ventilation for ≥ 48 h, and exhibited reactivation of CMV in blood were enrolled between February 5th, 2014, and January 23rd, 2019. Participants were randomized to receive ganciclovir 5 mg/kg bid for 14 days (n = 39) or a matching placebo (n = 37). Results The primary endpoint was ventilator-free days from randomization to day 60. Prespecified secondary outcomes included day 60 mortality. The trial was stopped for futility based on the results of an interim analysis by the DSMB. The subdistribution hazard ratio for being alive and weaned from mechanical ventilation at day 60 for patients receiving ganciclovir (N = 39) compared with control patients (N = 37) was 1.14 (95% CI from 0.63 to 2.06; P = 0.66). The median [IQR] numbers of ventilator-free days for ganciclovir-treated patients and controls were 10 [0–51] and 0 [0–43] days, respectively (P = 0.46). Mortality at day 60 was 41% in patients in the ganciclovir group and 43% in the placebo group (P = .845). Creatinine levels and blood cells counts did not differ significantly between the two groups. Conclusions In patients mechanically ventilated for ≥ 96 h with CMV reactivation in blood, preemptive ganciclovir did not improve the outcome.
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Affiliation(s)
- Laurent Papazian
- Médecine Intensive Réanimation, Aix-Marseille Université, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France.
| | - Samir Jaber
- Réanimation Chirurgicale, Centre Hospitalier Universitaire de Montpellier, Hôpital St-Eloi, Montpellier, France
| | - Sami Hraiech
- Médecine Intensive Réanimation, Aix-Marseille Université, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Karine Baumstarck
- Laboratoire de Santé Publique, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | | | - Nadia Aissaoui
- Médecine Intensive Réanimation, Hôpital Européen Georges-Pompidou, APHP, Paris, France
| | - Boris Jung
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Montpellier, Hôpital Lapeyronie, Montpellier, France
| | - Marc Leone
- Service d'Anesthésie-Réanimation, Aix-Marseille Université, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Bertrand Souweine
- Réanimation Médicale, CHU Gabriel-Montpied, Clermont-Ferrand, France
| | - Carole Schwebel
- Médecine Intensive Réanimation, CHU Grenoble Alpes, La Tronche, France
| | - Jérémy Bourenne
- Réanimation des Urgences et Médicale, Aix-Marseille Université, Hôpital Timone, APHM, Marseille, France
| | | | - Toufik Kamel
- Médecine Intensive Réanimation, Centre Hospitalier Régional, Orléans, France
| | - Qin Lu
- Réanimation Chirurgicale Polyvalente, Département d'Anesthésie-Réanimation, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, APHP, Paris, France
| | - Christine Zandotti
- Laboratoire de Virologie, IHU Méditerranée Infection, CHU Timone UMR190-Emergence des Pathologies Virales, Marseille, France
| | - Anderson Loundou
- Laboratoire de Santé Publique, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | | | - Jean Chastre
- Sorbonne Université, INSERM, Médecine Intensive Réanimation, Institut de Cardiologie, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Marie Forel
- Médecine Intensive Réanimation, Aix-Marseille Université, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Charles-Edouard Luyt
- Sorbonne Université, INSERM, Médecine Intensive Réanimation, Institut de Cardiologie, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris, Paris, France
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Carll WC, Rady MY, Salomao MA, Patel B, Singh VP, Sen A. Cytomegalovirus haemorrhagic enterocolitis associated with severe infection with COVID-19. BMJ Open Gastroenterol 2021; 8:bmjgast-2020-000556. [PMID: 33436481 PMCID: PMC7804824 DOI: 10.1136/bmjgast-2020-000556] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/05/2020] [Accepted: 12/11/2020] [Indexed: 12/19/2022] Open
Abstract
We present a case of haemorrhagic enterocolitis in a patient with SARS-CoV-2 who recovered from respiratory failure after support with venovenous extracorporeal membrane oxygenation. We describe clinicopathological features consistent with the systemic coinfection/reactivation of cytomegalovirus (CMV) concurrent with COVID-19 infection and the protracted clinical course of resolution of gastrointestinal inflammation after the treatment of CMV infection. Stool PCR, abdominal CT perfusion scan and histological examination of ileal and colonic tissues excluded enterocolitis secondary to other causes of infection (common viral, bacterial and protozoal gastrointestinal pathogens), macrovascular and microvascular ischaemia and classic inflammatory bowel disease, respectively. We propose possible synergistic pathophysiologic mechanisms for enterocolitis complicating severe COVID-19 infection: (1) T lymphocyte depletion and immune response dysregulation, (2) use of immunomodulators in the management of severe COVID-19 infection and (3) high concentration of ACE-2 receptors for COVID-19 virus in the gastrointestinal tract.
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Affiliation(s)
- Warren C Carll
- Departments of Pulmonary and Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Marcela A Salomao
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Bhavesh Patel
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Vijay P Singh
- Division of Gastroenterology and Hepatology, SC Johnson Research Building, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Griffiths P, Reeves M. Pathogenesis of human cytomegalovirus in the immunocompromised host. Nat Rev Microbiol 2021; 19:759-773. [PMID: 34168328 PMCID: PMC8223196 DOI: 10.1038/s41579-021-00582-z] [Citation(s) in RCA: 233] [Impact Index Per Article: 77.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 12/16/2022]
Abstract
Human cytomegalovirus (HCMV) is a herpesvirus that infects ~60% of adults in developed countries and more than 90% in developing countries. Usually, it is controlled by a vigorous immune response so that infections are asymptomatic or symptoms are mild. However, if the immune system is compromised, HCMV can replicate to high levels and cause serious end organ disease. Substantial progress is being made in understanding the natural history and pathogenesis of HCMV infection and disease in the immunocompromised host. Serial measures of viral load defined the dynamics of HCMV replication and are now used routinely to allow intervention with antiviral drugs in individual patients. They are also used as pharmacodynamic read-outs to evaluate prototype vaccines that may protect against HCMV replication and to define immune correlates of this protection. This novel information is informing the design of randomized controlled trials of new antiviral drugs and vaccines currently under evaluation. In this Review, we discuss immune responses to HCMV and countermeasures deployed by the virus, the establishment of latency and reactivation from it, exogenous reinfection with additional strains, pathogenesis, development of end organ disease, indirect effects of infection, immune correlates of control of replication, current treatment strategies and the evaluation of novel vaccine candidates.
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Affiliation(s)
- Paul Griffiths
- Institute for Immunity and Transplantation, University College London, London, UK.
| | - Matthew Reeves
- grid.83440.3b0000000121901201Institute for Immunity and Transplantation, University College London, London, UK
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Chamseddine S, Chmaisse A, Akel I, Zein ZE, Khalil S, Raad SA, Khati A, Ghandour H, Khafaja S, Haj M, Abboud M, Mahfouz R, Araj G, Zaraket H, Hanna-Wakim R, Muwakkit S, Dbaibo G. Epidemiology and clinical characteristics of viral infections in hospitalized children and adolescents with cancer in Lebanon. PLoS One 2020; 15:e0239258. [PMID: 32961548 PMCID: PMC7508634 DOI: 10.1371/journal.pone.0239258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 09/02/2020] [Indexed: 11/30/2022] Open
Abstract
Background Viral infections in children and adolescents with malignancy are commonly encountered and have a significant impact on morbidity and mortality. Studies and epidemiological data regarding viral infections in children with cancer in developing countries are lacking. This retrospective cohort study aims to assess the burden of viral infections in children and adolescents with cancer, by assessing prevalence, risk factors, as well as morbidity and mortality of common viruses over a period of 8 years. Methods and findings Medical records of cancer patients treated at the Children Cancer Center of Lebanon were reviewed and 155 participants under the age of 21 were identified with at least one documented viral infection during the period from July 2009 to November 2017. This subset included 136 participants with active malignancy and 19 participants with a history of cancer who underwent hematopoietic stem cell transplantation [HSCT] and were in remission; the latter group was analyzed separately. Information regarding participant characteristics, hospital course, and complications were obtained. Associations between viral infections and certain factors were assessed. In the cohort, 64% were male, 81% were Lebanese. In participants with active malignancy, 90% received chemotherapy in the 6 months preceding the viral infection episode, 11% received radiotherapy. 51% of participants were neutropenic at the time of viral detection, and 77% were lymphopenic. 17% experienced a bacterial co-infection, and 3 experienced a viral co-infection. Among 162 viral infection episodes, clinically diagnosed skin infections, mainly herpes simplex virus type 1 and varicella-zoster virus, were the most common [44% of cases]. These were followed by laboratory-proven systemic herpes infections: cytomegalovirus [14%] and Epstein-Barr virus [6%]. Respiratory viruses: influenza and respiratory syncytial virus, accounted for 9% and 4%, respectively, whereas rotavirus represented 11% and BK virus represented 3% of cases. Acute lymphocytic leukemia was the most prevalent neoplasia [57%]. Fever was the most common presenting symptom [55%] and febrile neutropenia was the reason for admission in 24% of cases. The mean length of stay was significantly longer in participants with cytomegalovirus infections and significantly lower in rotavirus infection. Admission to the ICU occurred in 9%, complications in 8%, and mortality in 5%. Participants with viral infections post-HSCT were noted to have a significantly longer length of hospital stay compared to non-HSCT participants, with no other significant differences in clinical course and outcome. The study was limited by its retrospective nature and by the late introduction and underuse of multiplex PCR panels, which may have led to underdiagnosis of viral infections. Conclusions Viral infections were prevalent in our sample of cancer patients and may have contributed to morbidity and mortality. Newly available viral diagnostics are likely to vastly increase the number and scope of detectable viral infections in this population. Prospective studies using multiplex PCR technology with systematic testing of patients will be more helpful in defining the burden of viral infections. Furthermore, efforts at antimicrobial stewardship would benefit from the identification of viral causes of infection and limit the unnecessary use of antibiotics in the pediatric cancer population.
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Affiliation(s)
- Sarah Chamseddine
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Ahmad Chmaisse
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Imad Akel
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Zeinab El Zein
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Suzan Khalil
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Sarah Abi Raad
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Antoine Khati
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Hiba Ghandour
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Sarah Khafaja
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Magda Haj
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Miguel Abboud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Department of Pediatrics and Adolescent Medicine, Children’s Cancer Center of Lebanon, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rami Mahfouz
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - George Araj
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hassan Zaraket
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
- Department of Experimental Pathology, Immunology and Microbiology, Faculty of Medicine, Beirut, Lebanon
| | - Rima Hanna-Wakim
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samar Muwakkit
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Department of Pediatrics and Adolescent Medicine, Children’s Cancer Center of Lebanon, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ghassan Dbaibo
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- * E-mail:
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Lee KH, Kwon DE, Do Han K, La Y, Han SH. Association between cytomegalovirus end-organ diseases and moderate-to-severe dementia: a population-based cohort study. BMC Neurol 2020; 20:216. [PMID: 32466754 PMCID: PMC7254693 DOI: 10.1186/s12883-020-01776-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 05/10/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The association between cytomegalovirus (CMV) and dementia remains controversial. Previous studies have suggested that CMV serostatus, as assessed by serum immunoglobulin G, plays a role in neurodegeneration with cognitive impairment. We aimed to evaluate the association between CMV tissue-invasive end-organ diseases and moderate-to-severe dementia. METHODS The ICD 10th revision codes from the National Health Insurance Database covering the entire population of the Republic of Korea were used to classify patients into exposed (n = 687, age ≥ 40 years, with CMV disease) and unexposed (n = 3435, without CMV disease) groups, matched by age and sex at a 1:5 ratio of exposed: unexposed. All non-HIV-1-infected subjects selected during 2010-2014 with a washout period of the previous 4 years were followed up until December 2016 to identify newly diagnosed cases of moderate-to-severe dementia. RESULTS Multivariate regression model (M3) adjusted for age, sex, low income, body mass index, transplantation status, malignant neoplasms, end-stage renal disease on dialysis, type 2 diabetes mellitus, hypertension, and dyslipidaemia showed a significantly higher incidence of dementia (odds ratio: 1.9; 95% confidence interval: 1.2-2.8) in the exposed group than that in the unexposed group. The risk of vascular dementia (2.9, 1.1-7.5) was higher than that of Alzheimer's disease (1.6, 1.0-2.6) in the exposed group in M3. In M3, patients aged 40-59 years with CMV diseases had a significantly higher risk of all kinds of dementia than those aged 60-79 and ≥ 80 years (11.7, 2.5-49.4 vs. 1.8, 1.1-3.2 vs. 1.3, 0.5-2.8; P = 0.025). CONCLUSIONS CMV diseases may be associated with the risk of moderate-to-severe dementia.
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Affiliation(s)
- Kyoung Hwa Lee
- Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Da Eun Kwon
- Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Kyung Do Han
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yeonju La
- Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Sang Hoon Han
- Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea.
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Sandonís V, García-Ríos E, McConnell MJ, Pérez-Romero P. Role of Neutralizing Antibodies in CMV Infection: Implications for New Therapeutic Approaches. Trends Microbiol 2020; 28:900-912. [PMID: 32448762 DOI: 10.1016/j.tim.2020.04.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 02/06/2023]
Abstract
Cytomegalovirus (CMV) infection elicits a potent immune response that includes the stimulation of antibodies with neutralizing activity. Recent studies have focused on elucidating the role of neutralizing antibodies in protecting against CMV infection and disease and characterizing viral antigens against which neutralizing antibodies are directed. Here, we provide a synthesis of recent data regarding the role of neutralizing antibodies in protection against CMV infection/disease. We consider the role of humoral immunity in the context of the global CMV-specific immune response, and the implications that recent findings have for vaccine and antibody-based therapy design.
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Affiliation(s)
- Virginia Sandonís
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), Madrid, Spain
| | - Estéfani García-Ríos
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Michael J McConnell
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Pilar Pérez-Romero
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain.
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46
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Schildermans J, De Vlieger G. Cytomegalovirus: A Troll in the ICU? Overview of the Literature and Perspectives for the Future. Front Med (Lausanne) 2020; 7:188. [PMID: 32500076 PMCID: PMC7243473 DOI: 10.3389/fmed.2020.00188] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/20/2020] [Indexed: 12/12/2022] Open
Abstract
Cytomegalovirus (CMV) is one of the most pathogenic viruses in human. After a primary infection, CMV resides in the host for life as a latent infection. When immunity is reduced, CMV can escape the suppressive effects of the immune system and lead to viremia and antigenemia. This reactivation, first seen in transplant patients, has also been documented in non-immunocompromised CMV-seropositive critically ill patients and is associated with higher morbidity and mortality. In the latter, it is not clear whether CMV reactivation is an innocent bystander or the cause of this observed worse outcome. Two studies showed no difference in the outcome of CMV-seropositive and seronegative patients. In addition, proof-of-concept studies investigating prophylactic antiviral treatment to prevent CMV reactivation during critical illness, failed to show a beneficial effect on interleukin levels or clinical outcome. Further research is necessary to resolve the question whether CMV replication impairs the prognosis in non-immunocompromised critically ill patients. We here give a concise overview on the available data and propose strategies to further unravel this question. First, post-mortem investigation may be useful to evaluate the effect of viral replication on organ inflammation and function. Second, further research should focus on the question whether the level of viremia needs to exceed a threshold to be associated with worse outcome. Third, clinical and biochemical assessments may help to identify patients at high risk for reactivation. Fourth, preemptive treatment based upon early detection of the virus is currently under investigation. Finally, immune-stimulating biologicals may be beneficial in high-risk groups.
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Affiliation(s)
- Jolien Schildermans
- Clinical Division of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Greet De Vlieger
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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47
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Abstract
Cytomegalovirus (CMV) reactivation has been described in adults with critical illness caused by diverse etiologies, especially severe sepsis, and observational studies have linked CMV reactivation with worse clinical outcomes in this setting. In this study, we review observational clinical data linking development of CMV reactivation with worse outcomes in patients in the intensive care unit, discuss potential biologically plausible mechanisms for a causal association, and summarize results of initial interventional trials that examined the effects of CMV prevention. These data, taken together, highlight the need for a randomized, placebo-controlled efficacy trial (1) to definitively determine whether prevention of CMV reactivation improves clinical outcomes of patients with critical illness and (2) to define the underlying mechanism(s).
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Affiliation(s)
- Hannah Imlay
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ajit P Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
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48
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Hraiech S, Bonnardel E, Guervilly C, Fabre C, Loundou A, Forel JM, Adda M, Parzy G, Cavaille G, Coiffard B, Roch A, Papazian L. Herpes simplex virus and Cytomegalovirus reactivation among severe ARDS patients under veno-venous ECMO. Ann Intensive Care 2019; 9:142. [PMID: 31872319 PMCID: PMC6928167 DOI: 10.1186/s13613-019-0616-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/09/2019] [Indexed: 12/12/2022] Open
Abstract
Background Herpesviridae reactivation among non-immunocompromised critically ill patients is associated with impaired prognosis, especially during acute respiratory distress syndrome (ARDS). However, little is known about herpes simplex virus (HSV) and Cytomegalovirus (CMV) reactivation occurring in patients with severe ARDS under veno-venous extracorporeal membrane oxygenation (ECMO). We tried to determine the frequency of Herpesviridae reactivation and its impact on patients’ prognosis during ECMO for severe ARDS. Results During a 5-year period, 123 non-immunocompromised patients with a severe ARDS requiring a veno-venous ECMO were included. Sixty-seven patients (54%) experienced HSV and/or CMV reactivation during ECMO course (20 viral co-infection, 40 HSV alone, and 7 CMV alone). HSV reactivation occurred earlier than CMV after the beginning of MV [(6–15) vs. 19 (13–29) days; p < 0.01] and after ECMO implementation [(2–8) vs. 14 (10–20) days; p < 0.01]. In univariate analysis, HSV/CMV reactivation was associated with a longer duration of mechanical ventilation [(22–52.5) vs. 17.5 (9–28) days; p < 0.01], a longer duration of ECMO [15 (10–22.5) vs. 9 (5–14) days; p < 0.01], and a prolonged ICU [29 (19.5–47.5) vs. 16 (9–30) days; p < 0.01] and hospital stay [44 (29–63.5) vs. 24 (11–43) days; p < 0.01] as compared to non-reactivated patients. However, in multivariate analysis, viral reactivation remained associated with prolonged MV only. When considered separately, both HSV and CMV reactivation were associated with a longer duration of MV as compared to non-reactivation patients [29 (19.5–41) and 28 (20.5–37), respectively, vs. 17.5 (9–28) days; p < 0.05]. Co-reactivation patients had a longer duration of MV [58.5 (38–72.3); p < 0.05] and ICU stay [51.5 (32.5–69) vs. 27.5 (17.75–35.5) and 29 (20–30.5), respectively] as compared to patients with HSV or CMV reactivation alone. In multivariate analysis, HSV reactivation remained independently associated with a longer duration of MV and hospital length of stay. Conclusions Herpesviridae reactivation is frequent among patients with severe ARDS under veno-venous ECMO and is associated with a longer duration of mechanical ventilation. The direct causative link between HSV and CMV reactivation and respiratory function worsening under ECMO remains to be confirmed.
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Affiliation(s)
- Sami Hraiech
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France. .,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France.
| | - Eline Bonnardel
- Magellan Medico-Surgical Center, South Department of Anaesthesia and Critical Care, CHU Bordeaux, 33000, Bordeaux, France
| | - Christophe Guervilly
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Cyprien Fabre
- CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Anderson Loundou
- CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Jean-Marie Forel
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Mélanie Adda
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Gabriel Parzy
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Guilhem Cavaille
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Benjamin Coiffard
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Antoine Roch
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Laurent Papazian
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
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Poh KC, Zheng S. A rare case of CMV pneumonia in HIV-infection. Respir Med Case Rep 2019; 28:100945. [PMID: 31709138 PMCID: PMC6831852 DOI: 10.1016/j.rmcr.2019.100945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/07/2019] [Accepted: 10/12/2019] [Indexed: 02/01/2023] Open
Abstract
Cytomegalovirus (CMV) pneumonia is a rare opportunistic infection in the setting of HIV (Human Immunodeficiency Virus)-infection. Establishing accurate diagnosis of CMV pneumonia in HIV-infection can be challenging. Co-infections by multiple opportunistic pathogens are common and a high degree of clinical vigilance to evaluate for multiple infections, including CMV pneumonia, should be maintained. As there can be a degree of overlap in clinical and radiological features amongst different opportunistic infections affecting the lungs, definitive microbiological and cytohistologic evidences are needed. Reliance on microbiological evidence of CMV in respiratory specimens alone for the diagnosis of CMV pneumonia will lead to an over-diagnosis of the condition and unnecessary treatment. In our case report, we describe a 53-year-old man with recently diagnosed HIV-infection who presented with non-resolving pneumonia. A diagnosis of CMV pneumonia was reached through consistent clinical, radiological, microbiological and cytologic investigations. The patient made a full clinical recovery after being started on anti-CMV treatment.
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Cantan B, Luyt CE, Martin-Loeches I. Influenza Infections and Emergent Viral Infections in Intensive Care Unit. Semin Respir Crit Care Med 2019; 40:488-497. [PMID: 31585475 PMCID: PMC7117087 DOI: 10.1055/s-0039-1693497] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Critically ill patients are admitted to an intensive care unit (ICU) for multiple reasons. In this study, we aim to analyze the current evidence and findings associated with influenza and other emergent viral infections, namely, herpes simplex virus type 1 (HSV-1), Epstein-Barr virus (EBV), and cytomegalovirus (CMV). Among medical conditions, community-acquired respiratory infections are the most frequent reason for ventilatory support in ICUs. Community-acquired pneumonia in a severe form including the need of invasive mechanical ventilation and/or vasopressors is associated with high mortality rates. However, after the pandemic that occurred in 2009 by H1N1 influenza, the number of cases being admitted to ICUs with viral infections is on the rise. Patients in whom an etiology would not have been identified in the past are currently being tested with more sensitive viral molecular diagnostic tools, and patients being admitted to ICUs have more preexisting medical conditions that can predispose to viral infections. Viral infections can trigger the dysregulation of the immune system by inducing a massive cytokine response. This cytokine storm can cause endothelial damage and dysfunction, deregulation of coagulation, and, consequently, alteration of microvascular permeability, tissue edema, and shock. In severe influenza, this vascular hyperpermeability can lead to acute lung injury, multiorgan failure, and encephalopathy. In immunocompetent patients, the most common viral infections are respiratory, and influenza should be considered in patients with severe respiratory failure being admitted to ICU. Seasonality and coinfection are two important features when considering influenza as a pathogen in critically ill patients. Herpesviridae (HSV, CMV, and EBV) may reactivate in ICU patients, and their reactivation is associated with morbidity/mortality. However, whether a specific treatment may impact on outcome remains to be determined.
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Affiliation(s)
- Ben Cantan
- Multidisciplinary Intensive Care Research Organization, St James's Hospital, Dublin, Ireland
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne University (Paris 6), Paris, France.,INSERM, UMRS 1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization, St James's Hospital, Dublin, Ireland.,Department of Pulmonology, Hospital Clínic de Barcelona, Universitat de Barcelona and IDIBAPS, Barcelona, Spain.,Centro de Investigación Biomédica en Red (CIBER), University of Barcelona, Barcelona, Spain
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